22611 (2) 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
Building Project Identification PER.MITNO.
Building Add ress: 22611
I o�k�RO yQ k\:
a one: aAppE=TM79U9RTrr7= -
arra me. 265 ,/ CITY OF CUPERTINO-BUILDING DIVISION
ntrador.Name: r^ Ic`(J70: APPLICATION / PERMIT
��/ 390 V BUILDING.ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. .LIC Nex
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcm: PERMITISSUANCE' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION '
'IMrebyaf(bmthatlamBcenaedunderproWonsofChapter9(mrrenrnc- APPUANCESRESIDENTIAL JOB DPSCRIPIION
(ng'Ifit cI. 7000)of Dlvisloo3oftheBusinexuand ProlessionsCode,and my . " s
license lsln���lyfor9R yqd dfea2.1 ` PAN /II/IMnn �rA� l.�
Lire las ^(il LIc.N J c7 ��ra-saI� l-.p'1 W /7 "
Date Contractor VY1,/ 201-1000 AMT'S
ARCHITECPSDE publknION I/
Q CZ I understand my pbre ehaB be used as public rccurdN OVER 1000 AMPS SQ.Fr.FLOOR AREA s 5/SQ.Fr'.
is (s
Licensed Professiowl
<< SGy3 SIGNS ELECTRICAL
q L D
Q OWNERxNLDER DECLARATION
�i SPECIALCItCUIT/MISC
i.., Thereby affirm that exempt Contractor's License Law for the
7Op u
following reon.(Sed1onsl
703L5,Bunessand Pmfesslona Code:Anydtyor TT2,(P,METER OR POLE INST.
ZZ countywhich requlresa peettoruuct,alter,Improve, m
deoLLsh,orrepalr
mmtr
TER
r4v anystm=mpdortoimlavuance,aborequimtheappBantforsuch,,r tto POWER DEVICES
a' Ok a signed statement that he Is Bcensol pursuant to the providom of the T
30 O
Contractor's License law(Chapter w� Pte 9(commencing the with Section 7000)of Divi-
SWIdMING POOL ELECTRIC smn3o(the Business and Pro/emlom Code)orthat heleexem thercfromand VALUATION
t+ 6 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLESSWITCHESFIXTURESI OD '0 a
applicant fora permit subjecino m
sthe applicant to a civil penalty of nore than
five hundred dollars($500).'4SQFT, STORIES TYPE CONSTRUCTION^ ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR.
> compensation,wllldothe work,ancithe structure V not Intended or offered for - -
O. silk(Sec.70/y Business and Professions Code:The Contractor's License Law
does not apply to an owner ofproperty who builds or lmprovesthereon,and t
whodoessuchworkhimxlforthrough hlsownemployees,provided that such OCC.GROUP RFS,UNITS
Improvements are not Intended oroffered for sale.If,however,thebuiiding or TOTAL: - -
improvement lasoid within oneyearofcompletion,the owner-bullderwill have
ft-bunicoof proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with llmnsed PERMIT ISSUANCE
mntractun to construct the project(Sec.7014,Businev and Professlom Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such piojecta with a ALTER-DRAIN&VENT-WATER(EM
If, Om
Bernard pursuant to the Contractor's License Law.
IBACK FLOW PROTECT.DEVICE FEE SUMMARY
L_I I am exempt under Sec. B &P C for this reason
OUTSI DE FEES
DRA)NSFLDDR,ROOF,AREA,GOND. SANITARY Y_ N_
Owner - Data RECF]IPI'N
WORK MAN COMPENSATION DECLARATION pp(�S.PER TRAP SCHOOL TAX Y_ N
MI hereby or( that 1 have tit lmun to of consent d pythaure,ora . RECEIPT N
centflLab of Workers Comperwtion lreurance ora anifled copythereof(Sec. GAS G.SYSTFIN-1 INCA OUTLETS PARK FEE ' Y_ N_
3800,lab C.) RECEIPT N
PolicyS p CAG. G
SYSTEM-OVER 6( I
Com any RECEIPT
DIVISION I'BI:S
r1CenNkd ropy i9 hereby famished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANGI-1ECK FEE
❑Cenif M ropy is filed with the city Inspection division.
CE IP TE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
OMPENSATION INSURANCE SEWER-SANITARY--STORM EA.2owr. - Date Recelpl#
(rhlaee on need of to completed if the permit Is for hundieddollam
($100)°`1 ') WATER HEATER W/VENT/ELFJCTR ENERGYFEE Y_ N_
Icenify hat int ped n afthe work forwhich this permit is issued,
[shall na 1 any rskn Ina manner so ob subject to the WATER SYSIE.i/TREATING PAID
WOrkefB s t want Id.Ddt hh
O Z Applies. - NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei t#
Z O NOTICE TO 1 : ,a r Ing this Certificate of Exemption,you .
should become eu Fct to th orke 'Comperwtlon provisions of the Labor TOTAL: TT
W Code,you rmtst(onhwlthm ly hsuch prowiom orthia permit shallbe
W a BUILDING FEE BV
doe. revoked.
CONSTR I N LENDING AGENCY SEISMIC FEE L
ll G Ihereby affrenthat there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
n Z ance ofthe workforwhlch this permit b lsxied(Sec.3097,Civ.C.)
U O Lender.Nano PLUMBING FEE
F tender.Address QTY. MECHANICAL PERMIT FEE
V' U Icenifythatl have read thisapplicatlonand date thatthab
cove lnfmoutlon MEGHANIGAL FEE
O W iscureect.I agmatocomplywith alldtyand county,ordinancesand state laws PERMIT ISSUANCE - FEES PAID:
Y1 relating to building comtroction,and herebyauthorize representativesn(this
f.. N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,IndemNly an d keep harrelem the City of Cupertino Date Receipt#
U
against liabilities,judgmenm,codsand expenses which may In any wayancei MRHANDLING(Mfr(rOt0,0D0CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgruturc of Applicant/Contractor Date D(HAUsTFIO0D(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppBvnt or future building occupant store or hand le hazardous HEATING UNIT 00100,000 BTU) Date ReceI t#
material as defined by the Cupertino Me meipal Code,Chapter 9.12,and the
I lcalth snd Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes - _No
Will theapplicanl or turn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I DATE
which emit havrdous air contamleants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,000 BTU) p1gg1
Yet II��11 No J T�
c mad the hazanuous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
i e Qh ma l Iealth&Safety Code,Sedlom 25505,25533 and 2553x. 1 f' J
nderstan thati(thebull drectamrrcNlyhavc a tenant,that It b my NEW REST DENTIAL MECI L SQ.FT
collo ity tonMity enc ant oftherequircmkntswhkh must be met �CuQ
uance of niflcate (Occvpan o ya`) l/\.`�•,y/
Ow a authorize agentA D.tA, TOTAL: ISSUED ItY:�k/✓ '1 tZ'
r
OFFICE COPY.