22651 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification - - PERMIT NO.
14
BYBdkg Address: - �� -a .. 22651
ro
arm; one: ,
Cjt ?, > CITY OF CUPERTINO-BUILDING DIVISION:
.dare N LI=.No: APPLICATION /PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECFIANICAL CATEGORY CONTROI,p
Arch ed/En neer: L No: - - .
^/M(r ^/ QTY' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: lbluaAl../. PERh9TISSUANCE� .❑ ❑ 11LICENSED CONTRACTOR'S DECLARATION
the a(firmthat lam lkmsedunderprovhionsof Chapter ( �APPLIANCMRESIDENTIAL JOB DESCRE'ITON
ingwith Sectlon7000)of Division3ofthe Businmandpa(n na e,andmyrommen
lienee is ht(u rce and effect. G •� 3 '; PANELS
License Class Lle V / `�•� ``y
I Date Contract. - UP TO IDO2DOAh
ARCHITECTS DECLARATION n
po± OAMPS
m Zp Iundemta d myplaashallbeusedsspubBcrecaris. OVERIOWAMPS 'I ,OR $/SQ.FT.
E ob(/ Licensed Profaeshmal SIGNS ELECTRICAL 'I t r �-'• 1��= x �`
OWNER-BUILDER DECLARATION SPECIALCE(CUIT/MISC �d T E R
�I., I hereby affirmlhatI am exempt the Conlrador'sLicense Law for the
following reason.(Section 70115,Business and Professions Code:My city or
O g TEMP.MECIR ORIOLE INSf.
county which requlmaperMttororutrud,alter,Improve,demolkh.arrepair 7
anystm=mpriortoibkmamealsorequimstheappUantio suchperMito POWER DEVICES DAT
file a signed statement that he Is Emoted pursuant to the provisions of the
3
Contmdor's License Law hapter 9(commencing with Section 7000)of Divi-
SWIMMING fat70L ELECTRIC
sb basis fa the elle e d exemption. Any violat ation
of exempt therefrom and VALUATION
Q a the basis for the alleged exemption. Any Nola Hon of nattySectiono nor arms
by any _ OUTLE7SSWITCHESFIX7'URES
applicant fees permit eubjectstheapp8nnt toe civil penalty of nor more thin J
five hundred dollars($500). NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the roe �'�' STORIES TYPE CONSIRUCTIOh'
property,sty,orhe employees r thelewk
compenmNon,will do Busimethework and the knot Intended oroffered for
q mk(Sec.704y Business and Professions;Code:The Conmadpre Liaae Law
don not apply to an owner of property who Wilde or improves thereon,and OCC.GROUP RIS UNITS
whodoessuchwprkhi..If rthrmghhisownemplpyeesprovidMthatwdL
improvements art not intended proffered foraale.If,however,the building" TOTAL:
improvementhsold withnom3varofcompletlon,theowner-W 0derwlll have
/ILe-¢urden of paving that he did not Wed or improve for purpose ofsate.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively con nu,ung with Ikeneed FLOOD TDNB APN
me Contra to co Liven thewprojectdoe(Ser.appy Business and of pre pn Code:
PERMIT ISSUANCE
The Contractor's imp's Limner Lw don nor ho apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
WIWa or improve Mursua and who mntreds (a each ptojem with a 'FEE SUMMARY
ryRj(admeempt pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt uMer Sec. B&P C for this reason
OUTSIDE FF
DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y + N
Owner - Data RECEIPT
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that I have a cedigate of consent to self-Insure,ora RhLE'I N
¢rt0aof Worken'Comperwtlonlwurance ora cedl(led copylM1ereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Poli,,Labb CJ REC 'F M
C.I4y R AS E
CEA.SYSIEM.OVER (E
Co y 4A)
BUILDING DI VI SION FEES
CertRkd copy h hereby fure"hed. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CedHied copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Chissectionneednabrcompldt ifthe NrnNtkforonehundreddollan SEWER SANITARY SRIRM EA.2DWT. Date Remi of
(Sm)orless3 WATER HEATER w/VENT/ELECTR ENERGY FEE Y N
I certlfythat in the performance of thework(orwhich this permit is hoard, —
1 shall an employ any tenon in any manner n as to become subject to the WATER SYSTEM/TREATING
Wmkem'Compeemtion Lawsof CaB(omia.Data PAID
_O Z" NOTICE
OTICE NEW RESIDENTIAL PLMB. SQFI', Date Remi tN
Z O NOTICEcome TO APPLICANT:If,after Workers
-Comenmaking this Ceion provisions
oft the
shouldbecomeat
titto the Wpr wit Comproviaeprovhionarmit s Lab or TOTAL:
LU N a` deemadre mustlorthwith comply with such proWlam ortM1h permit ahallW BUILDING
(L > deerted revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC PEE L
I hereby affirmthat them ha construction lending agency for the perform- TOTAL: ELECTRIC FEE
7 z �CSnce ofthe work for which this permit ie IssuedTS .3097,Civ.C.)
V O' lender's Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE
O W Icerti(ythat l have read thhappllaHnnand statelhatthe above Information MECHANICAL FEE
IL is correct.i agreeto comply with all city and muntyordinances and papa laws PERMIT ISSUANCE FEES PAID:
N relating tomilding coataction,and hereby authorae lrepresentatives otthb
F U) city toenterapoa the above-mrnomad property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemoify an d keep harmless the City of Cupertino Da[C Recei tic
agaWtlhbBlHn,odgments,c sandexpensnwhkh muyina wayaccrue AIR HANDLING UNIT(C010,000 CFM) SUBTOTAL:
ag.imtu.d Cl In=sequenaoftMgrantingo(thi. emit.
AIR HANDLING IIhTT(OVER IO,OW CFM) CONSTRUCTION TAX
Signaw Applicant/Contractor Mffe ENHAUST HOOD(W/DUCD CONST TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllcanfor nam Wgdingo pantstoreorhandkha rdma HEATING UNIT(TO 100,0DO BTU) Date Ci f11
material as defined by the Cupertino MurddpaI Code,Chapter 9.17,and the -
HealthandSafetyCodcSedion25532(a)7 HEATING UNIT 100,000 BTU) d -TOTAL:
F�I Yn No
-�TVat theippRam car tare Wilding occupant use equipment or devices VEMULATION FAN(SINGLE RESID) psL{s��SSUANfi'RR3ATE
which emit hanrdous air contaminants as de0ried by the Bay Area Air 0 �RJ�W`�a'a'",_-
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
YeaNo
have read the hazy-Rous materials requirements underChapler 495 of BOMER-COMP(OVER 100,000 BTU)
the California FlealtM1&SafetyCode,BMiorh 25505,25513 and 75534. I
undemtandphat notal Wilding does no pmrcenllyrnart. hick ghat Rhmy NEW RESIDENTIALMECIi. SQ.f•T.
eriorto Issi nc nal(ytheoccupanto(thercqulrcmenpewhkh rrwsl be co=t
' prior to issuance of Certifiers of Occupancy. ^
Ownerorauthorizedagenl Data ISSUED
TOTAL:
41
OFFICE COPY.