22132 (2) APPLICANT TO FILL IN INFORMATION WITHIN RE L NES - USE BALL POINT PEN ONLY
BuildingProtect Identification �
�•Jy �' - PERMIT NO.
.1 Ing A,;drcsl1 , /4VK- 6' - 22132
ners one. A
CITY OF CUPERTINO-BUILDING DIVISION
Contrictens Name: uc.Ne: APPLICATION /PERMIT
i
ArcMtect/Enginee
r Lic.No:
BUfLDING-ELECTRICAL-PLUMBING-MECFIANICAL CATEGORY CONTROL N
� ' arrY QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE F-1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that)amsion3oftheerprovlandPffhonsCodeanenc APPLIANCFSRESIDRNITAL JOB DESCRIPTION
IngwitI Ifull7000)0ld effeon3o(the Businessand Profel9onaCode,and my
I icense is in full f and effect PANELS "
License Lt.p
Date_ �Ractor
ARCHIECHI TECTS DECLARATION OVER 1000 AM
oto Z I understand my plats shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
WO
Licensed Professional SIGNS ELECTRICAL
Gro OWNER-BUILDER DECLARATION
1nFi{ SI'ECWLCBtCU1T/MLSC
t.., Z Thereby afOrmthatlam exempt Cont rectors License Law for the
T09/F.a following reason.f5cei..70315,Bishonsand Professions Code:Any dty car TEP MEEK OR POLE INST.
county which requlresa permit toconstmet,alter,Improve,demolish,°rmpa'r
W �a any"trocturc prlorto its lesuance,alsorequires lheapplicant forsuch permit to POWER DEVICES /
K C V ilio a signed statement that he Is licensed pure Cant to the provisions of the
Ou Contradors LlceveG lChapter9(mmmencingw,NSe IoR70001of Di v'-
If..3 of the Binces and PrefeasoCode)or that he exempt therefrom and SWENhBVALUATION
mns b NG POOL ELECTRIC � U
Q 5 the bases for the alleged exemption. dLE
tAny violation of Se 'on 7BILS by any OLEESSWITCHESFT%TURES z U
n t`c applicant fora permitsubineuitheappl'cans to a civil penalty of net nnrc than
five hundred dollars($500). NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
Z p, ❑I,as owner of the property,or my employees with wages as their sole
compensation,wllldothe work and thestructum b amintended or offered for
ale(Sec.7044,Business and Pro(ess'ore Code:The Contractors License Taw
g does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS,UNITS
F- who doeisuchworkhine Rorthr°ugh hisownemployess,provided that such
Improvementsamnmintendedoroffere forsale.ILhowever,thebuildingor TOTAL:
improvement bsold with'noneycarofcompldlon,the°wner-bWLderwlll have
tfeIurdeo of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor to censured the project(Sec 70K Business and Professions Cade:
The Contractors License law don net apply to an owner a property who ALTER-DRAIN&VENT-WATER ffN
holds or'mproves thereon,and who contracts for such projects with a FEE SUMMARY
cff,,&or(a)licensed Pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this rcMon :FEEq
GRAINS R,F7OOROOF,AREA,COND. SANITARY Y_ N_
" Owner Date RECEIVE N
WORKMAN COMPENSATION DECLARATION FIXTfJIiES PER TRAP SCITOOL TA% Y_ N—
RECEIPT hereby affirm that I have a certificate of consent to self-insure,ora T M
certif ate of Workers Compensation Tns°rance ora certified copythercof Sec. S FA4-
moll" bC.) GASEA. WCA OUTLETS PARK IFR Y_ N_
RECEIPT
Airy M GAS EA.SYSTEM-OVER4(FA)
Cumany BUILDING DIVISION FEES
C
�Certlfled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
nCertNed copy Is filed with the city Inspection division.
CERTIFICATE OF U MPTION FROM WORKERS' GREASE TRAP PAID
Date
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET.
(TMs section need net be completed If the permit is for one hundred dollar Remi lfl
($100).,1..) ENERGY FEE Y N
I certifythat In the perfo nceof thewo forwyyy'ccrh009 pe itlabound, I WATTAHRATERW/VENT/ELECTR —
I shall not employ any pc n in yky ma er ao,/ty.e�,� w the wATTx sysTraf/TRCATiNc PAID
Workers Compo on �9{C�ilfor Dat/e/ V./
O Z Applicant ✓ NEW RESIDENTIAL PLMIL SQ.FT. Date Recei ted
Z O NOTICETOMMI ANT:I,aRerm W.gthla Cediflateof Exemption,you
should become subject to the Workers Cempensatlon provlalons of the Labor TOTAL:
N Codr,you most forthwith comply with such provisions erthla permit shall be BUILDING ••E
deemed mvoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL M C Ihereby affirm Hut them Is a construction lending agency for the perform ELECTRIC FEE
7 Z are'ofthe work for which this permit is Issued(See3097,Civ.Q TOTAL:
(„) O tandem Name PLUMBING FEE
LL Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE'
O W Iooffy that i have madthb appl'ationand seawthattheaboveinformuse.
Is corms.Iagree tocomply with all city and county erd'nancesind state laws PERMIT ISSUANCE FEES PAID:
} W relating tobulkhrig corstiudlon,end Mreby authorize representatives ofthis
F city to enter upon the above-mentioned property for Inspection purpose.. ALT17t ORADDTOMECH.
Z (We)agree to ave,indemrdfy,and keep harmless the Cly of Cupertino Date Receipt#
U agalnsthabNtle",jad 'ms,coseand nonwh'chmaylnanywayacctue AIRHANDL1NGUMTEEOig000CFhD SUBTOTAL: . SO
against" dCity I, �me ft gfartiT this permit.
`���� AIR HANDLING ANTE(OVER 10,WOCFM) CONSTRUCTION TAX
igv m (Applicant/Contractor ateIXIIAUST HOOD IW/DUC"D CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTT) Date Recel tic
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the �[
Flealthand SafetyCode Snalo,2S532G)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ( ..V
❑Yes n No
Willtheappliant orfutere building occupant use equipment ordevices VENDLATIONFAN(SINGLERESID) ISSUAI�DATE
(,y lei which emit harardous air contaminants as defined by the Bay Area Air SLv.Y
.¢>•- r 'Quality Mamgement Distrid? BOILER-COMPOFB'OR100,00(i J"sws
❑Yes a�asTrT�
1' (have mad the lb v2No smaterials requirements under Chapter&95 of BDILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I I •.�� f` �_ee
understand that'fthebuild'ngdocsnotmrmntlyhaveaten..tthat it lsmy, NEWRESIDENTIALMEC11 SQ.I7.
responsibility to notify the occupant of the requirements which murt be rnet �•
prior to issuance of a Ced'fiate of Occupancy. T9iE.
Owner or authorized agent Date ISSIJIiU BY:J
TOTAL: s�-alAVCs+
OFFICE COPY