22313 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
Building Addre2 �� �. 22313
one: AMUCAUIONSUBMILTALDATE
a�✓f/ta r/C/ �e.L CITY OF CUPERTINO-BUILDING'DIVISION
Contranp�ss'&me: Lie.N. APPLICATION I PERMIT C9 J
lJ l'GW C
R6 6-a'06 BU(LDING-ELECTRICAT PLUMBING-MFLHAMCAL CATEGORY CONTRO S /c
Architect/ neer: - Lk.No: _ l'D
T ELECTRIC PERMIT FEE •BUILDING PERMIT INFO.
Address:-5p2-.7-/9 Vr/'eZln 517 of LLCPERMITISSUANCE ❑ El El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son L'cmeed under provisions of Chapter 9(commene- APPLI ANCESRESIDENTIAL JOB DESCRIPTION
IngwlthSection7000)ofDlAMm3oftheBusiness and ProfeatlonsCode,and my �'7�r'F�
�ila_ YI
license is In full force and effect. PANELS 1C. �.1.3 R
License Clam_Lic.#.
Data Contractor -ARCHITECT'S 701-1000 AMPS
NO O. I understand my plans hal be used as public records. OVER 1000 AMPS fjQ.�FIQQR&KEA
gLI...d Prafe.1mal SIGNSELECTRICAL p p g �f� g�
�4u61 OWNER-BUILDER DECLARATION kECIALCIRCNT/MLSC B�' 9 R N tl�
. IherebyarRrmthat lam exempt from the Contractor''sLkense law forthe 'tri U El
F�o folowing reason.(Section 7011.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST. 2D /^JO
countywhich requires a pernuttecorea uct,alter,Improve,demollsh,orrepalr F' / a ,
anystm=mprlortaibb ame,almrequimstheappluntfcesuchpermittoY.
(� file'a signed statement that he Is licensed pursuant to the provbioru of the POWER DEVICES
3O� Contradoes License Law(Chapter 9(commencing with Section 7000)of Dist-
Mo.
ist- SWIMMING TOOL ELECTRICslon3of the Business and Pro(emlaru Code)orthat hebexempt therefrom and VALUATION
he basis for the alleged exemption. Any violation of Section 7031.5 by any ^1
q� applicant for a permit subjects the applicant to a civil penalty of not more than OUTLETS-SWITCHES-FIXTURES o�Qs.
five hundred delta.($500). /
�pyy i,a.owner of the roe or m employees with we es as their sole NEW RESIDENTIAL¢E.TR SQ.FT. STORIES TYPE CONSTRUCTION
Q t»' ❑ property,work,a Y6
a rom(Sec.70K the.buse.ntionwilldothe Pr andthes Cdure Is ract:Th.Cotactor or..Led for
q sale(Bet.et apply
to an owner
property Code:The or Improves
Llcemelaw
$ who oessuclyloanownel ofpropertywho Wimorlmproovidedreoryand OCC.GROUP RES.UNITS
whodoement..arkhimaelfedorafferedhis ow le.If, eavever,thebthatsuch -
improvement6..Id intentledyearleredforsale.Ihemne-p Hderwilingoe TOTAL:
improvement beold withinoneyearofcompidiorythe owner-bulderwlllhave '
11,1 urden of pmvleg that he did not build or improve for ptu seofsale.). QTY. PLUMBING PERMITFEE FLOODTDNE APN
-j L as owner of the property;am exclusively mntrading with licensed pp yy ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code: -
The Contesdar's License Law does nd apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)'
builds or Improves thereon,and who mMddp
s fee such tok - -
cta with. FEE SUMMARY
- j0.t crer(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this reason
OUTSIDE FEES
Owner DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIKTURFS-PER TRAP SCHOOL TAX Y N
❑I hereby affirmorke-that I have a certificateInsurance
of acessm to set there() ora RE.EEI T M
3800,La C.Workers Comperuaticelnsuranceoracedifled copythereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y '" N
Policy
lab C.)
Po rC GAS EA.SYSTEM-OVER MM RECEO'CN
'Com any BUILDING DIVISION FEES
❑pCertlfled copy is hereby ththe GREASE/INDUSERL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy b filed with the city
ty Inspection dlvWce. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASC•TRAP- PAID 111�]
- COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI ate Re.i n L(,J F
Qhiasedion need not be completed lithe permit)sfes one hre
undd dollars
($100)orlem.) WATER HEATER W/VENT/¢EGTA EN ER Y N
I certifythat re the performance of thework forwhlch W.permit la Issued, -
I shall not employ an7 person in any manner so as to become subject to the WATER SYSTFM/TREATING
Workere Compensation Laws of California.Date - PAID
OZ Applicant - + NEWRESIDENTIALPLMB. SQFT. Dafe RQ 1 t#
Z.Q NOTICETO APPLICANT:IL after making this Certliuleof Exemptlod,you '
~
should become subject to the Worker'Compensation provisions ofthe Labor TO AL:N cc Code,you mu at forthwith comply with such provisions orthb permit shall be IN FEE
� deemed revoked.
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE _
Thereby affirm that there is a construction lendingagency for the perform- ELECTRIC FEE
Z ance of the work forwhich this permit b Issued(Sac.3097,Civ.C.) TOTAL:
U O Iender'c N. I PLUMBING FEE
U. F- L.end.e.Addrem QTY. MECHANICAL PERMIT, FEE. MECHANICAL FEE
Iudifylhatlhre
aveadthlsapplcatio..Mstatethadheaboveinformation
O W
1 .b correct.Iagreeto comply with all city and county ordinances and statelaws PERMITISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthb
H mv U) city to enter upon the abmentioand property for iespedion purposes. ALTER OR ADD TO MECH. Date RECO Iii
V z (We)agree to save,indemnify,an d keep harmless Ne City of Cupertino
aganuthabilitles,judgmen sandexpenses which may inanywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTO AL: 7
agausa said CI n ue of the gaming of thl.permit.
ajy „/ .? MR HANDLING UNIT(OVER 10,00()CFM) CONSTRUCTION TAX
-
Sig^rcof Applc /Contractor ate EXIIAUSTHOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant;r future building occupin some or handle hazardous HEATING UNIT(TO 100,000 BTU) Dake Rece #
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health❑Y and Safety CodeSSectiion 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: s
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE" I,
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DITP OR IWCM BTU)
- Yea nNo. sr1W�
4havereadthehazar�ommateriabrequlrementsunderChapter6.95of BOILER-COMP(OVER 100,000BISn ,�//
the Calilomia Health&Safety Code,Section 7550x,75533ani125534. 1 V
understand that lithe building does not currently have.tenant,that ltbmy NEW RESIDENTIAL MECH. SQ.FT. !
responsibility to notify the occupant of the requirement.which at be red
Prior to issuance of a Certificate ofoodipancy.
Owner or authorized agent , Data '« ISSUED 6Y:
TOTAL:
OFFICE COPY