22422 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PFRMITNO. Z 4 2 Z
Building Address:'
L ' � ' P : .0 r l Ins • `iEb iLl
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D9 Y' \ X1 _A . }p 11114 p CITY OF CUPERTINO-BUILDING DIVISION Q�
ntraRoraNarpye a� Lk.No: APPLICATION 1 PERMIT.
1 BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Amhit /Englncer, Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ' 0 ,y ❑
' YJ_UI;
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
Ihereectionmtlutl1Aawn3 ofthe ushuseialoneof Cssions9(emmenn APPLIANCESRESR)EM7AL
Inense1SeMon force and died. otthe Bustneseand ProfeestonsCode,and my
license Isla(uB force and erred PANELS
License Claw Cmdr - s
Data Contractor
ARCHITECT'S DECLARATION 2W-1WOAMPS
mO ZZ I understand my plans shall be used as pubbe records. OVER 1000 AMPS S .FT.FLOOR AREA S/SQ.Fr.
t' Licensed Professional SIGNS ELECTRICAL
uuuu�llli �
OWNER-BUILDER DECLARATION
I herebyaffirm that Iam exempt fromthe Contractor's License Law forthe SPECIALCIRCUIT/M15C ��
O Z—P following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST. 1)
countywhichrequlresapermktocomn d alter,impmve,de=lB h,orrepair . '1r' G•,? 15 1
anystmct mptlormitsissuame,alsonqulmtheapplimntforsuchper tto POWER DEVICES 1V,n'YI IBt R'YtiA-'
r file a signed statement that he B licensed pursuant to the provisions of the V V
}gg}((O w Contractor's License Law(Chapter 9(commencingwith Section 7000 of Divi-
p don 3 of the Business and Professions Code)orthatt he is exempt therefromand SWIMMING POOL ELECTRIC - J?,.'„s LUAIWN
o the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESI7X'I'UItES
applicant fora permit subjeclathe applicanito a civil penalty of not more than
QQ five hundred dollars($SM.
NEW RESIDENTIAL ELECTR SQ.bT. STORKS TYPE CONSTRUCTION
WWW ❑I,as owner of the property,or my employees with wage as their sole
compensation,willdotheworrofedtbestmde: heis Cmdactoentended oicansoffered Law '
saie(Sec.7o94,Buabsas and Professions Code:The Contractor's Llcerse law
does not apply to an owner of propertywho builds or Improves thereory and OCG GROUPRES.UMTS
who dowsuch work himself or through hisown employees,provided that such
improvements are not Intended oroffered for ask.If,however,the building or TOTAL:
improver:entks idwithlnoneyearofcompl&i mtheowner-Wilderwill have
t4L�u rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE C�
contractors to construct the project(Sec.7094,Business and Professions Code:
The Contractors License Lw does not apply to an owner of property who
builds or Improves Nereory andwhocontracts for such plujects with a ALTER-DRAW k VENT-WATER(EA)
on actors)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B.k P C for this reason �sIX FLOW PROTECT.DEVICE
OUTSIDE S
DRAINS.FLOOR ROOF,AREA,COND, SANITARY Y_ N_
Owner Date - RECEPT#
WORKMAN COMPENSATION DECLARATION 0 FDOTJRFS.PMTRAP � � SCHOOLTAX Y N
F-11ffi
I hereby arm that I have a mfim
rtite of consent to self-insure,or a RECENT N
rertifcide of Workers'Compematlonlmurancema certified ropythereof(Sec. - GAS,F.A.SYSTEM-1 INCA PARK FEE Y N
3800,Lab CJ RECEIVE If
- GAS EA.SYSTEM-OVER d(EA)
' Co.Cm � 'BUILDING DIVISION FEES
Certified copyishereby(uMshed. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE.
❑Codified copy is filed with the city UspectWn division. -
CERTIFICATE OF EXEMPTION FR OM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ' SEWER-SANITARY-MRM RA 20017 Date Recei t#
Qhb section need not be completed If the permit B forose hundred dollars
(S]00)rifyth
I certify that WATER HEATERW/VENT•/ELECTR ENERGY,FEE Y_ N
at In the performance of the work lorwhkb B
hfhis permit Issued,
I shall net employ any person In any manner so as to become subject to the
Workteers'Compensation Laws of California.DaWATER SYSTEM/7RFA77NG PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQXT. Date. Recei t#
Z O NOTICETOAPPLICANT:II,aRermakingthBCertlfloteof Exemption,you
should become subject to the Workeri Compensation provisions of the Labor TOTAL:
V) Code, must forthwith comply with such rovisiois orthis permit shall '
W > deemed revoked. Py P - . BUILDING FEE
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby af(Irmthat there is a construction lending agency forthe perform ELECTRIC FEE
d TOTAL:
Z ante of the work for which this permit B Issued(See.3097,Civ.Q
V O Lenders Nacre PLUMBING FEE �s
H Lender's Address QTY. MECHANICAL PERMIT FEE
O WIcedifythatlhay .adthisapplkatlonandstatethattheabov¢Information MECHANICAL FEE
Ismrrect.I ugree to complywith all cityand counlyordinances and state laws PERMIT ISSUANCE FEES PAID:
} 1 relating to building construction,and hereby authorize representatives of this -
(— W city to enter upo above-mentWned property for lnapMlon purprses. ALTERORADDTOMECH.
2 (We)agre ve,Indemnify an d keep harmless the City of Cupertino - Date Rxeipt#
V against Ila ' ,}ndgmemsconnand ses-ld ylnanywayaccrue AIR HANDLING UNIT CTO 10,0DO CFM) SUBTOTAL:
agaWts ioronsHryenceof ming '.Par
a pegrdt.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
'tIgrj4ryof Applicant/Contractor to I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX,PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will thea applicant or futurebulldin ccs ant store orhandle hazardous HFATING UMT(TO 100,000 BTU)
PP Bo P Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and safety Code Section zss3z(a)e � HEATING UNIT(OVER 100,001)BTU) TOTAL:
❑Yea u No
Will theapplicnt orfuture building occupant use equipment or devices VENTILATION FAN,(SINGLE RESID) DATE
which emit hazardous air contaminants as cleaned by the Bay Area Air ,
a lity Management District? BOILER-COMP OHP OR 100,000 BTU) JU I,Ai,wast,s
Iu�__I Yes ❑No �(aYbWU111f
v Ihave readthe hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,OW BTU) -
�' the California Health&Safety Code,Sections 75505,75533 and 25539.1
understand that If the building does not currently have a tenant,that it la my NEW RESIDENTIAL MECH, SQ.Fr. p
o lR
prior
responsibility notifyCerts i occupant of the requirements which nwst be mot t"+
prim to Issuance o(a Certificate of Occupancy. "'� '�-.y,� �.p•,..,�
Owneroraulhwuedagent Date ISSUED It
,i TOTAL:
OFFICE COPY ..