22583 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PEILMITNO.
sot Building Address: 225831072
5 PFO!///J//f(/G/�P 9/t �'i( a7IILO
neve one: A A
3UVf / /-//LC 7f83K7 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: LIc.No: APPLICATION /PERMIT
a ( 4
BUILDING-FbL MCALPLUMBING-MLCHANICAL CATEGORY CONTROL N
Architect/Englneer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ],�0 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Herel under provisions
erprovivlonsol Chapteoenc APPLIANCESRESIDENTAL JOB DESCRIPTION
Ingwith Socti..7000oDii.kn3.fthcBuslnesand ProfnsimnsCd,a.d
my
license Is In full force and effect PANELS
//,D N 'pLlmCas Loc.N
Date _Contractor
ARCHITECTS DECLARATION 201-1000A,MPS
ereuZ I understand my plans stall be used es pubhcrecords. OVER1000AMPS SQ.Fr.FL AREA $/SQ.FT.
E V LIcevM Professional SIGNS ELECTRICAL
FGGGG y OWNERex exempt
DECLARATION f j s� fl n
SPECIAL CIRCUIT/MISC L V d Of�' ,CJY
Ihereb af0rtn that exem from Contractor's License law for the
F following reason.(Section 70715,Buslnen and Professions Code:Any city or AAV51
county which requires a permit to ceratmd,alter,Improve,demolish,orrepalr 7FMP.MhTQR OR POLE INST.any Stiulturo priorto its Issuance,also requiresthe applicamfornuchpernet to POWER DEVICES E-4ellfl
�_4r.
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors Llcerue Law(Cha er9(mmmencin Ith Se ion7000)of Dlvl- VALUATION
N R w SWIMMING POOL ELECTRIC
O slon3o(the Buslnessand ProfessbvCode)orthat he is exemptthere(mmand
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
. e hundred dollar%500). NEW RESIDENTIAL ELECTR
M1,as owner of the property,or my employees with wages as their sole —SQ-Fr. STORIES TYPE CONSTRUCTION
peneation,wnlaothe work anathe structure la not Intended or offered for
5 0 sale(See.7064,Business and Pruesslons Code:The Contractors License law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP .RES.UNITS
who doessuch work himselforthecugh his own employces,provided that such
Improvements are not Intended oroffered for sale.It however,thebuilding er TOTAL: 1.s CD
improvement bso)d wllhinoneyearolcompletion,the cwner-bullderwill have
tK
enof proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Las owner of the property,am exclusively corstracting with Ilrenaed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pmfnslov Code:
The Contrador's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such ppocts with a
of dJaaorti)Brensed pursuant to the Contractors License Law. FEE SUMMARY
LII am exempt under Sec, B &P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINSFTOOKRCOF,AREA,COND. SANITARY Y N
RECEIPT 0
VRKM COM ENSATION DECLARATION FUTURES.I'EEt TRAP SCHOOL TAX Y_ N
p ❑1 he eby affirem that I have a certificate of consent to self-Inwm,or RECEIPT N
f, certificate ofWorkers'Compemationlesurance or a certified mpythereof(Sec. GAS EA.SYSTEM-1 INC.40I17LETS PARK FEE Y N
3800,Lab C.)
RECEIPT
Policy N CAS EA.SVSIFAI.OVER 4(EA) BUILDING DI VISION FEES
C. any
�Cchifled copy la heed with the cit. GREASE/INDUSTRLWASIEINTFRCE'TOR PLANCHECK FEE
❑cemnea ropy la filed with the city Inspection awiaiom.
CERTIHCATTOFO(EMP ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT DRIC RCC21 t#
(fNssectlon need not W completed if the permit Is for one hundred dollars
($I00)orlcas.) NATER HFATERW/VENT/ELECTR ENERGYFEE Y_ N_
1 certify that lo the performance mf the work fmwhich this pemmt is issued,
I shall not employ any person In any manner so asto become subject to the WATER SYS.IEM/TREATING
Workers Compensation Lawa o(Call(ornla.Date PAID
OZ Applicant NEW RF9DENT AL PLMB. SQFT.
P: Date Recel t#
Z O NOTICETO APPLICANT,If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
tY N Code,you at forthwith comply with such provisions or this permit shall be BUILDING FEE
W deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyaflrmthat there is a construction lendingagency forth,perforrryELECTRIC FEE
n Z aoce.fthr workforwhichthla permit is Issued(Sec.3097,CIv.C.) TOTAL:
U2 Lerderb Name PLUMBING FEE
LLF" Leedees Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U l certlfythatl have mad thisapplicationand state thatthe above information
O W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. IL relating to building construction,and hereby auflumce representatives ofthis
(— Z city to enter upon the aWve-mentioned property for inspection purposes. ALTIRORADDTOMDCIL
(We)agree to save,Indemnify an d keep hated.the City mf Cupertino Date Receipt#
U against llabillties,)udgemets,coats and expenses which may in any way same AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: U
.gat eatea(d CityAnc apro the granting of this permit.
`///!/4Y7/ AIR HANDLING I1h7T(OVER IO,OWCM) CONSTRUCTION TAX
/ SI at eof Applicant/Contractor Daze E%HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pp0cant orf.dum Wilding occu pant store or hand le baeardous HEATING UNIT(TO t 00,000 BTI) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
I leahh and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: .0
❑Yes M No
Will the applies est or future W ilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air eve amivnts as defined by the Bay Area Air Plus)A PD
Quality Management District? BOILER-COMP GHP OR 100,000 BTU) rN
4Yea ❑❑No
have mad the), r ous materials requlremcnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 11/� 1
the Californla 25
Health&Safety Code,Sections 25505,25533 and 34. 1 AUH REM
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT Ill li
responsibility to notify the occupant of the requirements which must be met
prorwesuanceof.cedificateofoavpancy. NNY1�CU*I%
TOTAL: /p
Owner or authorlced agent Date ISSUEDBY.. J�Y/r✓L- IA
v
OFFICE COPY