22710 (2) APPLICANT TO FILL I F MATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tlulldin Pro en i
Bu / / PFRMITNOrllrQBuilding Address: ' F,— ^271 O
nes ams:� ane G G I
CITY OF CUPERTINO-BUILDING DIVISION G�
G lr'rtOr''� j�{ LIe Npg't APPLICATION / PERMIT 1 Q�
BUILDINC—MM RICAL�PLUMBINGMECIIAMCAL CATECOR✓ CONTROL a
Archlteat/Lngtneer: Llc No:
I� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
icarseI I.fan 7000)ot it affect. ofthe Buslnenand ProleselonsCade,and my /'1_ /
Lt...Class
la s to.and effect. PANELS1/-
Llan.Clam LIL.X
Data ContractorUP TO 2a[LAMPS
ARCHITECTS DECLARATION 701'1000 AMP"'
lopW+��w,Q2�Q... lunderstand my pion shall be used n public records, OVIiR I000AMPS SQ.IT.FLOOR AREA $/SQ.Fr.
cd)
Limosed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Z� Ihereby a(flrmthat lam exempt from the Contractor's Llan.Law for the
G
following...(S°nlon 7031.5,Business and Promolons Code:Any city or TSMC METER OR POLE INST.
county which requiresa permit romnslruct,allep Improve,demolbh,or repair
Onystmmm prlortolts Issuance,also requ4esthe appliantforsuch permit to POWER DEVICES file a elgned statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
Bion 3of the Bush.and Pmfuaiom a
Code)orthat he is ern therefmnand VALUATION
F o the bash for the alleged exemption. Any violation of Section 7031S by any OUTLETS SWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more Iban
five t.as o nerdolof the pr. SQ.Fr. STORIES TYPECONSIRUCTION
,9ti,Cc NEW RESIDENTIAL ELECTR
�n ❑enaownerll the property,or and
employees Inwlthwaga as offir ered
le fo
Hn compensation,&. 044,will Bothe work and lhestrucle:The Contractors
Intended or License
Law
.1.&.apply
toBusiness,
ow adProfessions
propeav Cade:TM or impown Liame Law
�,I R does oeapplytornownerofpropertywhobuildsorlmprovntherroryand OCC.GROUP RES.UNIT'S
0.0. whodoes
am nothimself ndedorwghhbown aleph owe, erthedthatauch _
Improvements ere not Intended proffered lw sale.If,howeveq thebuildingw TOTAL:
improvement baold withinoneynro(complelloMlheowner-builderwlll have
tfr*rden of proving that he did not build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE F7AOD70NE APN
j_f I,as owner of the property,am exclusively contracting with licensed
mnt.cror ec to construct the project(S 7004,Busmen and Prof estmus Cade: PERMIT ISSUANCE
The CordraRor's License Lew does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
builds or improves thereon,and who contracts for such p(ojem with a
dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under Sec B&P151 C for this reason BACK FLOW PROTECT.DEVICE
DRAINS-FLOOR,ROOF,AREA,CONI). _SANITARY Y N
Owner Date RECEIVE If
WORKMAN I have
DECLARATION FDn UREcr PER TRAP SCI100L TAX Y N
❑1 hereby affirm that I have o lmuate of consent to opythsurc,ora RECEIPT X
38Mtaleo(Workere'Compeuatlodlosunna oraartltled mpythereof(Sec. GAS EA.SYSTEM-1 ING OUTLETS PARK FEE Y N
3800,Iab C.) / C
RME
Pollryp C 5 g[Com TX GAS LA.SYSTEM-OVER BUILDING
DING DDIVISION FEES
❑Cedifled copy b herebytumie ed. GRLASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy is(fled with The city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTrARY-STORM EA.2BOFr. Date Remi t#
(Thle.ctlon need not be completed If the permit b(or ow huntlred dollars
(5100)wlen') WATER HEATER W/VENT/FJ-FxTR ENERGY FEE Y N
a
I rtify that N m
the performance of thework forwhich this permit is Issued, —
I shall not employ any person In any manner.ss in become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lavard California. Date PAID
O Z Applicant Date Rerni t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ.FG
Fshould become subject to the WorkerCompensation provisions of the Labor TOTAL:
W Code,you=at forthwith comply with such provisions or this permit shall be -
LU 1 darned revoked. BUILDING FEE
CL OI CONSTRUCTION LENDING AGPNCY SEISMIC FEE
I hereby af0rmthat there Is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
O O Lender's Nam° PLUMBING FEE
IL H Lender'.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtifythatlhavemadthbappliatlonaMpatethatlheawvelnformation
fl, bcorrect.I agree to complywlth all cityand county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby amhoriae representatives of this
[— city to enter upon the above-mentioned ove- entioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z
Z (We)agree to save,ind emnlfy an it Date ReCeit#keep harmless the City of Cupertino P
age I bIBtiesIs
,jadg n ,ewtsand expenses which may in anyway accrue AIR}IANDLINGUMT(T010,000CFM) SUBTOTAL'
ago 1 d In con of of the /v�a�I�,TLrr AIRITANDUNG UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
,ergiahumo plionl/Carta or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
NAZAR U MATERIALS DISCLOSURE
Will the appllant or foto uildibgoccup.m1n.m.,h.odichicardous HEATING UNIT(TO 100,000 BTU)
material as&Ancd by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei t#
I Iealth and Safaty Code r�Section 75532(.)? HEATINGUNITER UT(OV100,000 BTU) TOTAL:
❑Y. u No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DIsWct7 , BOILER-COMP(3FNOR 100,IX0 RTU) M&T
'Ph Yn 4 No
ave read Healthe h
sur pus rCode,Le rcons 255 5,2553 and 255 4.1 of BOILER-COMP(OVER 100,000 B'I'lJ)
the Caltfornta}Iealth&Safety Code,Settlors 25505,75537 and 75537.l r fa(J I 0 ,94
undenlandlhat notify
the occupant
note require encs which that b boy NEW RESIDENTIAL MCCN. SQ.IT. P'
rnspoeuibility to notify the oempant o/the requirements which muss be ne[ pWaa.1)
prior to Issuanco of a Certificate of Occupancy. city of�U R9
Owner or authorized agent Data ISSUED BY: XS
TOTAL:
OFFICE COPY