22450 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro od Identification - - PERMIT NO.
B.9diagAddraMe �;,v22450
1' a"'e: '' 1 one: A A
BOn! CITY OF CUPERTINO-BUILDINGDIVISION ^�
a�rT8Nd11ej L+=Na APPLICATION / PERMIT
/� 7
• ArcMtect/Engineer. Lic Net BUILDINGELECTMCAI MLTMBINGMMHANICAL CANARY CONTROL p .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 4 Se TPERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION � Er
I Mreby.fit.that l am licensed under provisions of Chapter 9(commuse. APPLIANCESRESIDENTIAL
—�
Ingwilh Se ion7000)ofDiviN-3ofthe Buanewand ProfesaonsCode,andmy OBON
L'car is In (a and affect. PANELS
Llan Cla, ( LRCM x W^�� S� C,t`�, Q
Date Contractor �JpgJ�� Yfk VOa_ i/as-8L`((`,,��.
q �CxITECI'S E %r1�11e 201-1000 AMPS - L 0.'m rJt
aO Zp Iunderatand my place shall used wpuhlicrerorde. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
�j Licensed Professional SIGNS ELECTRICAL UA L F— ® IN .II
t6 OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MLSC- 6� �V1
Z.�4 1 hereby affirm that I am exempt form the Contractor'.Lima.Law for the (�
Q (oVowing reason.(Section 7031.5,Business and Pref Gagers Code:Any city or TEMP METER ORPOLE INSE. IE IB'dacVU'
r 4I'd =ntywhichrequimapermltwcommd alter,impmve,de=lV h,ormpair J�
anystmct mpdortolts+mamealmrequimatheappUmntforsuchper tto POWER DEVICES
Ole a signed statement that he is licensed pursuant to the provisions of the
w0� Contractors License Law(Chapter 9(mmmencmg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
slo.3ofthe Business and Professions Code)orthat he hi exempt therefrom and VA ATION
'3 the basis for the alleged exemption. Any violation of Section 7031-.5 by any
G applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSW[TCI-IFSE[XIT3RES
O five hundred dollars($500).
I,as owner of the property, NEWRESIDENTIALELECTRSQ}T. STORIES TYPE CONSTRUCTION
�n ❑ p ork,a orhe employees their
compensation,Business
work mdthes Code:Thee 6 Coot ntractors
intended or License
d for
Mile(Sec.apply
to anew owner
fpmpcProfeselty Code:The Contractor.Warne Taw
$ whodoes oeat apply loan owner ofproperty who Wilds or improvesihareoryand OCC.GROUP RES.UNITS
F whodoes.uchwork MmseBathrough his own employees,provided that mch
improvements are not intended oroffered forsale.If,howevep thebullding car TOTAL:
impmvemontbsoldwlthlnaneyearofcompldiorytM owner-bullderwlll have
it den of paving that he did net build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTAODZONE APN
tv as..at of the property,am exclusively contracting with licensed I'ERM1.L ISSUANCE �1
contractors to construg the project(Sea 7044,Business and Pro(ewlons Code: L.CV
The CantmcMr'e License Law does nal apply a an owner of property who
Wilds or ALTER-DRAIN&VENT-WATER
improves thereory and who contracts for such Projects wOh a BIA)
coactor(.)licensed pursuant W the Contractors License Law, - FEE SUMMARY
I am exempt under Sec. B Is P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N— '
RECEIPT B.
.WORKMAN COMPENSATION DECLARATION p1XTURESPFR TRM O SCHOOL TAX Y N
❑1 hereby affirm that I have o imua/e of consent to self-hou
ora .� RECEIPT 9
certiO=area(Worken'Comperisatmnlruurana ora certified copy tM1ereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
Polk Lab CJ PARK FEE Y N -
Pollrytl RECEIPT
Como s(T_(]Y GAS EA,SYSTEM-0VERd(EA) - BUILDING DIVISION FEES
Certified
soppy sTTie d withly the
cityed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with[M city Inspection division.
CERTIFICATE OF EXEMFrION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANFTARY-STORM EA 2DOFI Date Recti t#
(Thfssedion need notbecomplded](the permit V foronehundrcd dollars
($100)orfy,th) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[certify employ
any personIperformance of any
m weaknner f,as to b co permit rt,to the —
I shall not employ any Lam In any manner w w to become eubject to the WATER SYSTEM/TREATING W
Workers Compensation Lawn of California.Date PAID -
Z' 'Applicant
Z (7 .NOTICEco APPLICANThe aRerrs'Co Certificate o(Exemption,eLyou
NEW RESIDENTIAL PCMB. SQ.Ff. Date, ' Recei t#
Monil
Ced,you=at me sub0ct
co plywit'such pruation provisions permit s tab be TOTAL:
> dermad
mled.forthwith comply with euchproarlslon.orchis permit shall be BUILDING FEE
CL
� deemed revoked. -
W p CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
a Thereby afOrmthatthem+eamrutructlon lending agency forth perform TOTA !ELECTRI FEE
� Z ance of the work for which this permit Is issued(Sec.3097,C1v.C.) ° FEEE a�O renders NameLender.Addrew QTY. MECHANICAL PERMIT FEE ICAL FEEO WIcertitylhatl have read thlsappllatlonaM gatethattheaboveln(ormation IL iscorrect I agreeto complywilh all city and county ordinances and gate laws PERMITISSUANCE D:relating to building construction,and hereby imthortee representatives of this
city to enter upon the above�mentloned property for Wpection purposes. ALTERORADDTOMECH.(We)agree to save,indemnify an d kap harmless the City of Cupertino Receipt#
against liabilities,judgments coslsand expenses which may in anywayacorue AIR HANDLING UNIT(To l0,OW CFM) SUBTOTAL:
against City in consequence of the granting of this permit MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigaaareof Applicant/Contractor .Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous HEATING UNIT CM 100,000 BTI]) . Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand SafetyCode Secti 32(a)7 HEATING UNIT(OVER 100,OOD BTI,
❑Yesonex TOTAL: C7 0
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) Ir56ft DATE
which emit harardous air contamiha.a s as defined by the Bay Area Air
Qu alicy Management District BOILER-COMP QHP OR 100,0M BTU) ) y '
4Yes ��'us
haverniaHeath& ouM yCode,Sstions2m05,2553 ad2S534.I5of BOILER-COMP(OVER100,OW BN) My
the erstan tatifthbSafety Code,Sections25505,ve.tand25534.I u ,
understands onlhfy the occupant
not erreuireme is tenantmost It met NEWRffiDENTIAL MECFi. SQ.Ff. (/f
res WismytonastythecatooftoflherequUertnnlswhich mustMrant
la isauantt is iflate o(Ompanry. ,
nero aul oris. agent Date - ISSUE/
TOTAL:
OFFICE COPY