22435 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification 7 PERMIT NO.
Building Add.,: 22435
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C [ Rs3 yd CITY OF CUPERTINO-BUILDING DIVISION. ��
Contrachas Name: Lie.No: APPLICATION /PERMIT —L A G BUILDING-aECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lia No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: p` S d q C, &09 f tarp PFR)ATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby effirmthat l am licensed under provisions of Chapter9(rommene- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwithSedion7000)of DiAsion3ofthe Susimmand Profemi=sCode,and my I L
Li nm Is In fuB pre and erten. / PANES
Dale Contractor19 UP70200AMPS
ARCHITECT ECLARATION If 201-1000 AMPS
0w rZ$r�. Iundentandmypkroahanbaumdupubhcremnia OVER IOW AMPS RAREA $/SQ.FT.
Fi ZT: Licensed Professional 9CNS ELECTRICAL 11 m—i—i-ise
<�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISCNessirR
Z F, � Iherebyaffirmihatiam exempt(romthe ConlnctorLLlcense lawfor the
togowing reason.(Section 70115,Business and ProfeuWns Cade:An d or ' /
F1' muntywhkhmqul ape ttommt d,alter,tmpro kdem itsh,orrepar TEMP METER OR POLE INSID
E)
anystmu mprlortaikW ame,alsomquirestheappliunt(wsuchpermltto POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3w Con3ofthe Rusin License Law rof.alr9(mnurancingwOhmmpt hemfm and SWIMMING POOL ELECTRIC VALUATION
BOJ dan30f the Buslnuaand Profamlona Code)orlhat hekaumpttherefromand o/(l7/1
the bask for the alleged exemption. Any Violation of SMbn 70315 by any OUILETSSMTCHMFLXT URFS O Q'
applicant for a permit"b)ects the applicant to a civil penalty of nor more than 1O
True undreddolWhepro NEW RESIDENTIAL ELECTR SQ.FI'. STORIESTYPE CONSTRUCTION
�n I,a owner l the property,or h. employees with wages u their sok
N—le H 44,Business and Pmfeathe sC de:The Contractors
r o Larne Law
D cote(Sec.IMC,Business and Profueproperty Code The or improves
hereon Law
�$ -h.ddoes apply tom owner thmgh so nemporimprov Weds atmch OCC.GROUP RES.UNITS
whodoe.encs an n himself ed mattered
how,e provided thatch
improvementssonotintended earofcd pletioe.ILhowever, alder ill have TOTAL;
Improvement ksold withlnone yearofcompldlory lhcowner-bullderwlll have
IhAjZurden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE H.GODZONE APN
Luj L as owner of the property,am exclusively mntnning with licensed ppgM1T ISSUANCE
contractors to construct the project(Sec.7(l Business and Professions Code:
The Conmdori License Law doss not apply to an owner of property who ALTER-DRAIN&.VFM-WATER(EA)bunds or tmprovea thereon, sad who mntnns for such p(o)ems with
ogBt[adorW licensed pursuant to the Contractors License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec 0&P C for this reason
OUTSIDE
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT#
PER TRAP SCIIOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to seB mFDCIURES-loa
,or• RECEIPT N
3800 LateolWnrken'Compeuatlsn Wunnceoracert0led copythereof(See. GAS BA.SYSTEM-1 INCAOUILRTS PARK FEE Y N
3N W,Tab CJ rC, �� n RECEIPT*
Policy tl ` L
Com an CAS G.SI'STT7d-0VER�(EA)
Y BUILDING DIVISION FEES
Certified copy is hereby thcity
e city inspection division.
furnished.
C]Certified ropy k filed withhthe GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 100171. Date Remi tis
Qhia seniors need oat be camplMed if the Permit k(Drone hundred dollars
(SI MAllem.J WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertifythat In the performance of theworkforwhkhthis permit bk"ed,
1°hag saw ploy any pe n Ina y manner so a o b me bon to the WATER SYSTEd/TREATING
Wwken' pe orlon sol Vomit.Dae PAID
OZNUILC sat NEW RESIDENTIAL PLMB. ' SOFT. Date Remit#
PZ NDT[GE TO PL ANT:IL ager making thl rtlicete of Exemption,you
shouldbesubject to the Workers'Compe tion provisions of the Labor TOTAL:
" (A m Code,you moat forthwith comply with such provisions orthk permit shall be
cc j deemed revoked. OUILDINQ ELE .2 e)40
M G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there Is a construction lending agency for the perfomF TOTAL: ELECTRIC FEE
Z ance of the work for which this permit k Issued(Ser.3097,Civ.C.)
U O Landers N. PLUMBING FEE
IL Lendee.Aadr, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O I certilythat l have readthkappllcatlonand datethattheabovelnformation
M krorted.I agreeto comply with all city and countyordinancea and pate laws PERMITISSUANCE ES PAI
> U) relating tobuildingmrmt"dion,and hereby authorise representatives ofthk / p
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH. Date Reeei t#
_ (We)agree to save,indemnity an d keep harmless the City of Cu pert inn
against lkbilWes,judgments,costs a nd expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicem/Contractor Dam EXHAUSTHOOD(W/DUCE) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfmum building oaopant store or handle havardous HEATING UNIT(TO 100,000 BTU) Date Recei l#
materkl as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the
Ilealth and Safety Code Section 75531(a)7 FIRATING UNIT(OVER 100,000 BTU) TOTAL;
RYu No
Bitheapplka t was building.pantuwequipmentordevicu VENTILATION PAN(SINGLE REBID) IS ATE
which emit haaardous air contaminants as defined by the Bay Area Air
Quality Management District? BDR,FR-COMP OHPOR 100,0D BTU) g
4 Y. No JUL
havereadthe Faaa nus twterlak requlremenb underChapler6.95 of BOILER-COMP(OVER IW,OW BTU) 12
the California Health& fmyCode,Sediom8505,15S33and15S3a.]
understand that if the building dues not currently have.tenant,that it k my NEWRESIDENTIALMECH. SQXT
r spomibilityto notify the occupant of the requi came t.which mu.t be mat A{WUW71l�
to...rce. a�CrrtifjcaLc of occupancy. �'V w vsamwar
�z 9 In v
Ow nor aur orlaed agent f,
ISSUEDBY.
TOTAL
OFFICE COPY