22806 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PE1twTNo.
Ituilding Adders,: 22806
f10415 k 71 M R nn : - AA
var s aeM: _ A
II1I,, _T % skp Y 3-ILA-3 aior CITY OF CUPERTINO-BUILDING DIVISION /�1l�
A
n(C t &.MN i LIc.No: APPLICATION / PERMIT t
�. AZT& m blTs 1'! 1 2( BULLDINGELECTRICAL-PLUMBINC-MECHAMCAL CATEGORY CONTROL
rehlectlaglneer. U Li&No:
L�P v QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: �I N 4r U�� PERMITISSUANCE ❑ ❑ �/ El
CONTRACTOR'S DECLARATI N L�7
I hereby affirm that l am heensed under provisions ufChapter 9(cvmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing with Section 7000)of Division 3 ofthe Businessand ProfessionsCede,and my
license is In ful fo and effecit (/:� PANELS Q ^^
License Crlagps I onced "1 �..,r[�� •�'
DatelO- 1— 11 CHIna4or 201-1000AMIS
UP TO 2DO AMM
ARCH ll baus DECLARATION OVFRIWOAMIS SQ.FT.FLOOR AREA S/SQ.Fr.
a Z I understand my plan stall be used v public records
Edo Licensed Pro(eask al SIGNS ELECTRICAL ^
�QW OWNER-BUILDER DECLARATION SPECWNn E
LCIRC
T/MISC �i ,Ii / '� D I N
7 Ihercbyafflrenthat lam exempt fromthe Contractors License Law for the
'SOH following reason(Secilon 7131.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. f
FSQ,� cauntywhichrequimapermittocovtr d,alter,impmve,demolbh,ormpair ,�v� �! T E R
aa anystmctum prior to its Issuance,alsorequine,IheappOant forsuch permit to ((POWER DEVICES
p�O a V Ole a signed statement that he b licensed pursuant to the provisions of the /
Qom^,fn Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DATE oN
O sion3 ofthe Business and ProfessensCoic)orthat heisexempttherefromand )
S^S the basis for the alleged exemption. Any violation of Section 7071.5 by any OUILETSSWI1CFTESHX'ILRES /
�GS app0ontfora permit subjects the applicant to a civil penalty of not man,than
a five hundred dollars($SM. NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
.. ❑I,as owner of the property,or my employees with wages as their sole
C�< compnaation,wBldo the work,and the structure ls not intended or offered for
❑ sale(Suc.7014,Busines.and Profession,Code:TMContnctoes License Law
SS docs not apply to an owner of property who builds or improves thrown,and OCGGROUP RES.UNITS
who docssuch work hine ell or through his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebuliding or TOTAL:
Improvement Ls sold within oneyearofcomplation,the owner-builderwlll have
t1glZurden of proving that he did not build orlmprove for purposcofsale.). QTY. PLUMBING PERMIT FEE FLOOD LONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the perfect(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or improves thereon, and who contracts for such plojeci.with a FEE SUMMARY
c actor(.)licensed pursuant b the Contractor's License Law. BACK FLAW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR A,ROOF,ARECOND. SANITARY Y— N
Owner Date RELEII'TI
WORKMAN COMPENSATION DECLARATION pp(TUREf]'ER TRAP SCHOOL TAX Y— N—
❑1 hereby af(Irm that I have a ceni(late of consent m ast!-Inure,ora • RECEIPT M
certificate of Workers'Compevatlan Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FFR Y N
3800,Lab C.) 1\� —
I'olicy p IO Q G;J 1 RECEIPT If
On
anv CTK[T—I A GAS EA.SYSTEM-OVER4(EA) BUT LDI NC DIV]SION FEES
0 Certified ropy V(fled withh tthe CertlON a copy is here tcity inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
he
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
CCCI IN
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017. Date
(This section need net W completed if the permit b for ons hundred dollars R
($100)or less) WATER BEATER W/VENT/ELECTR ENERGY FEE Y— N—
I cenifythat In the performance ofthe work forwhlch this permit Is issued,
1 shall not employ any person In any manner soypco bjM to the WATER SYSTIM/TRFATING PAID
Worken Compp �tW�L,wa of Glifo u.D a u C/
O Appllant'�Sl—O/A n� NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z 0 NOTICET APP A'f (,aRe gt art to of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
41 Code,you euxt forthwith comply with such provisions orthis permit shall he BUILDING E
� > deemed revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hereby affirm that there isaconstradton lending agency fmthe perform TOTAL: ELECTRIC FEE
Z ance ofthe work for which this permit ls Heard(Sec.3097,Civ.C.) PLUMBING FEE
(� O lender.Name
LL ~ Lc.deraAddmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 mnBythatl have read theappBationand statethatthealan information
11 Lsorect.I cgreeto comply with all city and county ordlnancesand state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authomm,representatives ofthls
F city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
2 Date ReCeiptq
(WO agree to save,Indemnify an d keep harmless the City of Cupertino MR HANDLING[TMT(T010,000 CFM)
V against liabillli ,judgments,costsand expenses which may In aeywsyamme SUBTOTAL:
against Bald I^mn.-uen of the granting of Parodi CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CRM)
w. CONSTRUCTION TAX PAID:
Sigvturcal Applicant/ ontractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appllo nt or future building occupant store or ha odle,haranlous HEATING UNIT(TO 100,000 BTU) Date ReceI til _
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the /yam
Hralthand Safety Code Section255324)7 HEATING UNIT(OVER 100,000 BTLfi TOTAL: �W
❑Yes M No
Will the applicant orfeum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
/! i'n whicheret havrdous air mntamimnts3s defined bythe Bay Arca Air
Quality Management District?
BOILER-COMP(3FI'OR 1 W,IX10 BTU) P^eD
qYen Q No PJ
4havereadtheh mousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER100,000 BTU)
the Glffc mia Health&Safety Code,Sect Ions 25505,25533 and 25534.1
' undentandthatifthebuildingdoesnrn.rrentlyhavcatenant,thatitismy NEW RESIDENTIAL MECH. SQ.FT. O
responsibility,to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. �ia4'�j
Ownerorauth.nmdagent Dae TOTAL: LMSUEDBY:
OFFICE COPY