22045 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Pmtort Identification PLIfMITNO.
But ding Address: 22045
Vo,3 ak .i!/, C.`i e
ser.Isons:
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ova Z 7-/ ene: 2 CITY OF CUPERTINO-BUILDING DIVISION �f-111
Cnntraetn:aNa IIw� �gli up.Ne: APPLICATION I PERMIT
✓✓� BUILDING-ELECTMCALMUMBINGMECHAMCAL CATEGORY CONTROL#
Arehi /Engineer: I Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addn:as: PERMIT ISSUANCE I [I ❑ V 1:1 Lm that EDCONTR under SDECLA RATION L(_7 L`J
I hereby aff[rmthatl ivsion3 ofthe usinesislomof Chapter ode,an mo- APPLIANCES JOB DESCRIPTION
Ingwlth5ect1on71100)0(Dlvldon3 ofthe Bustnessand Pro(esslonaCode,and my
It cense Is in fug fo end off eR. //"tI, a PANELS J
License Class Lic.N- �G>'/�! •-s.
TT/ " Comr etm UP TO 200 ANTS
ARCHITECTSDECLARATION 201-l(KMAMPS
❑W wW X I undemtand my plaru atoll be usM public records. OVER I"AMPS l� SQ.FT.FLOOR AREA f/SQ.FT.
00
ha L Fj Licensed Professional SIGNS ELECTRICAL 'I ,_ I: '1
6
OWNER-BUILDER DECLARATION l.✓
Ci Fit SPECIALCBICUIT/3,115C I / r
IherebyafRrmthatlam exept form the Contractor.License Law for the FB—�
g fo8ow ng reason.(Section 70317 Business and Pmlesslona Code:My city or TEMP.METE OR POLE INS,.
5 rountywhichmqu4 apermittomme ct,alter,impmve,dem Ill h,orrepalr c
anystm=mpdortoitsisauance,aleorequireatheapplimntforwchpermitto POWER DEVICES
.tile a signed statement that he b licensed pursuant to the provisions of the
O u, Contractor:License Law(Chapter 9(commencing with Section 7000)of Divi-
!`•:, SWIMMING POOL ELECTRIC
�O slon3ofthe 0uelnese and Prefevlaw Code)orthat hebexem thereformand VALUATION
S the basis for the alleged exemption. Any violation of Sections 70315 by any OUTLETSSWITCHESFIXTURES
'�<S applicant for a permit sub"the applicant to a civil penalty of not room tban
GAO five hundred dolWs(S.500). ES CONSIRUCTION
$ NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE
I,as owner of the a property,a or my employes with wags as there door
k 7.0 compendation,wWnea;.nork,aessio strumsrebnod Intended cuie oroffered for
..Lw
5�O sak(See 7044 B.uslnessand Professlom Code:The Contractols Llcemue law
$ does not apply to an owner of property who Wilda or improves thereon,and
c who doessuchwork himselforthrough hisownemployees,provided thatsuch OCC.GROUP RFS.UNITS
Improvements are not Intended proffered foreale.If,however,the W ilding or TOTAL:
improvementisseidwithln oneyearofcompletlon,the mvner-builderwill have
try,Ifamen of proving that he did net wild or improve for purpose of axle.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
LJ L as mune,of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contouamst.to.muct the project(Sec.704q Business and Professions Code:
no Commences License Law does not apply to an owner of property who
Wilds or improves thereon, and who mntraM for such pkpjecb with a ALTER-DRAMkVENT-WATER(EA)
cgnIJctor(s)Rmnxd pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEI'TN
WORKMAN COMP EN'SATION DECLARATION1 .NQS .gyp `l`(�^ SCHOOL TAX Y N
M1 hereby a(flrm that I have•certificate of consent to self-Insure,ora ` PER C RECEIPT M
cediflate ofWorken Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) RECEIPT
cNN
Policy N GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
pm CrrtiRed copy la;hereby furnished. CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certifed copy is filed with the city Inspection division.
CERTIFICATE OF FXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200Fr. Dale Recei t#
(This section need not be completed If the permit le forone hundred doilam
IBlOo)Om less.) WATER HFATE2 W/VENT/ELFCTR ENERGYFEE Y_ N_
I certify that ti the perforwnce o(the work forwhkh this pennll is Jawed,
1 shall not employ an/person in any manner so ad y9 be �ct to the WATER SYSTEM/TREATING PAID
Workers Comprysait Ir life ate_ f -
0 Z
Applicant /lY'�4�.C/ NEW RESIDENTIAL PLM6. SFT. Date RttCI t#
Z O NOTICE TO APPLICANT:If,4 rmakingthd Certlkamid Exempt ion,you
Fehpuld become aubFct to the W odomr Composation proWlomofthe Labor TOTAL:
W Code you most forthwith comply with such provisions orthb prrtmt shall be BUT DING at)
W > deemed revoked.CONSTRUCTION LENDING ACENCY SEISMIC FEE t
11 I herebya(firmthat there is a construction lending agency for the perform- ELECTRIC PEE
0 Z ance of Leder.Name PLUMBING
which this permit Jai taxied(Sec.3097,Civ.C.)
TOTAL:
00 I<nae.•a Name PLUMBING FEE ( Ltio
LL ~ R.ender.Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have madthisappliationanl statothauheawve Information
V correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating tobutlding construction,and hereby authorize representstivesofthis
F cityto enterupot the awvcmeotioned property for inspection purposes. ALTER OR ADDID MECH.
Z (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Receipt#
V against Babilltks,pdgrmnta"sandexpenseswhkh mayin anywayacaue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said City in consequence gifthe granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigmture of Applicant/Con Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD US MATERIALSDISCIASURE
Will the appBant or future building occupant store or handle hazardous HEATTNC UNIT(TO 100,000 BM Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
H,.hhand SafetyCode Ion 25532(a)P HEATING UNIT(OVER Iffy"SM TOTAL:
Yno
Willtheappiicant or future building occupant..equipmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havmom air cent res m ants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 10,000 BTU1
4Yea I/; ��f
havemadthehazarUousmaterialsrequlrementsunderChapter6.95of BOILEWCOMP(OVER IW,OWBM ao�
the California Health k Safety Code,Sections 25505,25533 and 25534. 1
understand that lithe building does not currently have.truant,that it b my NEW RESIDENTIAL MECH. SQ.FT.
responsibilityto notify the occupant ofthe requirementswhich most be mM 1" AAT
prior to issuance of a Certificate of Occupancy. 1�7��
Owner or authorized agent Date TOTAL: ISSUED BY�'�
OFFICE COPY