22401 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Buflding Addd�rcw: I ' /� { ( , q�. L7}1 ,1— / 36 22401
er.Name:1�1{� `}- Loo ane: ��`�R lJ
P CITY OF CUPERTINO BUILDING DIVISIONt A A
contr et.e. arpe: Lk.No: APPLICATION /PERMIT
' BUILDING-ELECTRI&L-PLUMBING-MECFIANICAL CATEGORY CONTROL N
IRW Architect/Engineer. Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE eo ❑ ❑ ❑
LICF.NS ED CONTRACTOR'S DECLARATION
IhthS on 7OOhe(Dimsiensed under ftheBuprovhlons dpmfcsMm.r.d.,.d c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingweh Sectulifin eandeffre n3o11he BudmsswdProlesdon.Gude,and my ^
license isia(uB fors and e.0 - PONTISLl.
Date Class Lont l
Date Contractor —UP TO 20DAbMS
ARCHITECT'S DECLARATION 201-1000`YAPS
at rO. I understand my plans shall be used ER as public retards. OVTWO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
dFi Licensed Professional SIGNS ELECTRICAL
6 u� OWNER-BUILDER DECLARATION SpECULCIRCNT/MLSC
Z p,irA� 1herem
byafErm that am exempt frothe Contractor's License Law for the
pp following mason.(Section 70315,Business and Professions Code:Any city or
OZi-fa� TEMP.METEftOR POLE 1NSr. L
rm �` coustmcnuh requima permBm alsorouireatheapmvgdeosuch,arto
any atructure priortstatement
ahat he is lice sed pursuant
t the pro visionofpermit e f{OyygR DEVICES
file a signed da/emmnt that he V licensed pursuant to the provisions of the
Off^ Cmractor.Lic..Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
do.3 fthe Buslnessand Pmfessloro Code)oethal he d exempetherefromand VALUATION
ii the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXIUItFS
appMuntforapermltsubjeetstheapplcantmadvllpenallyofnas mlban
five hundred dollars(SM. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sok
C compensation,will do the work and the structure is not intended or offered for
Y 0 sale(See 7004,Business and Professions Code:The Contractors Limead Law
B does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RFS.UNITS
who does such work himeelf or through his own employees,provided that such
bnprovements arc not intended oroffered lorsale.IL however,thebuilding or TOTAL
Improvement) wldwithlnoneyearofcomplmWmtheowner-buflderw011 ve
t"rdenofpmving that he did nolbuldorimpreveforpurposea/axle.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor to coratruct the project(Sec.7094,Business and Professions Code:
The Carl'Actor's License Law dm not apply to an owner of property who
Wild. or hop.thern,eoand who contracts for such pLojecta with a ALTER -WATER(EA)
cLJ
gB�Tactor(s)licensed pursuant to the Contractor's Unman Law. FEE SUMMARY
I am exempt under Sec 0&P C for this cOUTSIDE FFrc
reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owner Data RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SOKDOLTAX Y N
111 hereby e!llrm that I have•mrtiflcam ale of consent 10 self-Imre,ore RECEIPT N
cemlflLab of Worker'Comperwtlon frau'Ans ora certllkd copy lhereo(f$ec. GAS EA.SYSIFM-1 INCAOUTLETS PARKFEE Y N
Policy
Lab CJ
Co.llry M RECEEGAS F.A.SYSTEM-OVER 4(EA) DING I N
Cany BUILDING DIVISION FEES
rtllledcopy is hercbytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
rtltled copy b filed withh the the city inspection division.
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Recei t#
(I'hlewction need not be complMed lithe permit Bier one hundred dollen
(5100)orl`ss.) WATER HEATER w/yFxp/p pGTR ENERGY FEE Y N
I certifythat in the performance of the weak forwhlch this permit is Issued,
I shall not employ any person In any manner w u to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RE9DENTIAL PLM B. SQ.FT. Date Recei t#
ZC) NOTICEco esubjettothe after oakingtensation his profscate of Exemption,you
should become subject to the Worker'Camperaatbns rthis peofthe(aloe TOTAL:
� N deemeduowel forthwith comply with such provisions orthk perMtshallbe -BUILDING
IL � deemed rooked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemby affirmthat there b a construction lending agency for the perform-ee ELECTRIC FEE
Z once ofthe work for which this permit is Issued(Sm 3097,Civ.C.) TOTAL:
V O Lenders Name PLUMBING FEE
LL f Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I celifythat l have read this application and datelhatthe above information
1 is correct l agree to comply with all cityand county ordinances and date laws PERMITISSUANCE FEES PAID:
} U) relating to building construction,and hereby authorize representatives of this
(• Z city to enter upon the above-mentioned properly for Inspection purposes. ALTER OR ADDTO MECH.
— (We)agree to save,indemnify and keep humless the City of Cupertino Date Receipt#
against liabilities,pdgmems,cods and expense.which may in anywayacnue AIR HANDLING UNIT(17010,0DO CPM) SUBTOTAL'
ago t said City In consequ ence of the grant Ing of this pemmt.
AIR HANDLING UNIT(OVER 10,0)0CFM) CONSTRUCTION TAX
J
Sig re (Appicant/Contractor m I— EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Blore or handle hazardous HEATING UMT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and the Date Recei Pt#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ YesI l No
Will the applicant or lure building oeevpart use equipment or devices j VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanaolous air cont rmeants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,000 BTU)
1-1 Yea 1—I No 4 au +
Nol have read the haza mus materials requirements underChapter6.95 of BOILER.COMP(OVER 100,000 BIT)) � �
gt•s�
the Calffemia Health&Safety Code,Stolons 25505,25533 and 25534.1
understand that if thebuilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. d*s�l'5l
responsibility to notify the occupant of the requirement.which at be mot
Prior to lasuans of a Cert lficate of Occupancy.
1�fyj
Owner or aumorlud agent Data ISSUED���Y
TOTAL.:
OFFICE COPY