22448 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Pro'ert Id—I flrelon 7 PERMII'NO.
Building Address:Isco 22448
2; .
Fvw
QxL am k� one. A A
CITY OF CUPERTTNO-BUILDING DIVISION
• Contnder. .me: un.Ne: APPLICATION / PERMIT `7—1 �� I
LicBUILDING-ELECTRICALMUMBING.MECHAMCAL CATEGORY CONTROL#
ArrhitM/a ter• .N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrtxe
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affm,that l am 0crneed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTLON
ingwith Sedlon70D0)of Division3ofthe Businessandprofes .,Code,andmy
license Is in full force and effect. PANELS
License Clam LIC#
Date Contrador a.a r2� �/-} 0
ARCHITECTS DECLARATION 201-1 030 AMPS
`47 I understand my platuahaB be used as public nerds OVERIMAMPS SQ.FT.FLOOR AREA $/SQ.FT.
wO
V(Cj
Licensed Professional SIGNS ELECTRICAL
Qto UID
OWNER-BUILDERFd SPECIALCIRCUIT/M1SC
F' � Thereby affirm that lam exempt from the Contractor's License law for the R
F 9 f- following mason.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE IN T
rountywhich requlrna permit toconstruct,alter,improve,demolish,ormpair
anystrudurc prior to its issuance,abo requtmsthe applicant for such permit to MOWER DEVICES /}/J
file a signed statement that he Is licensed pursuant to the provisions of the
OaG
Contractors License Law(Chapter 9(commencing with Section 7000)of Dist- SWIMMING POOL ELECTRIC DA it
30 alon3ollhc Busincu antl Professions Code)orthat he Vexem thercfromand ' ALUATION
a �'S the basis for the alleged exemption. Any Violation of Section 70715 by any
OUTLE'ISSWITCHESHXT JRFS l
cypQ fiveapplicantdredapedollars U50)ecestheapplicant teactvil penalty c(not morcthan O) Q�cW
o' roti
five hundred as
owner of
NEW RESIDENTIAL ELPGTR SQ.ET. STORIES TYPECONSfRUCTION
�j ❑e as owner of the property,or my employees with wages r thele dole
compensatlon,wlll dotWwork and the atmdurc e,noHntendM or offered for
Jule(Sec.7W4,Business and Pr fesslons Code:The Contractors License law
$ docs not apply to an owner of property who Wilda or improves thereon,and
F�^ who does suchwork himselfor through hisown employees,provided that such OCC.GROIII' RFS.UNITS
Improvements are not Intended proffered for sale.If,however,the building or TOTAL:
improvement issold within oneyearofcompletion,the owner-budderwlll have
I en of poising that he did not Wild or improve for purpose of Jule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
tractors to cautioned the project(Sec 7004,Business and Protesters Code:
The Contractor's License Law does net apply to an owner of property who pL]II4-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptopcts with a FEE SUMMARY
m ador(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
u I am exempt under Sec. B&P C for thin mason
OUTS I DE FEES
DRAINS FLOCK ROOF,AREA,GOND. SANITARY Y_ N_
. Owner Date RFOEIxI'N
WORKMAN COMPENSATION DECLARATION FDnURFS.PER TRAP SCHOOL TAX Y N
❑l hereby affirm that I have a cenl0rate of consent to selFlnsurc,ora RECEIPT N
cenlflrateof Worken'Compensatlonlmumnceoracenifie .pytheseof(Eec. GAS EA.SYSTIM-t INGd OUTLETS PARK FEE Y N
380Q Lab CJ RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(FA)
am raBUILDING DIVISION FEES
CCenyified copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cenlfled copy 6 filed with the city inspection division. <a
fry 7S
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID 1-17-9/ JI'
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. Date Remi t#
Old,section need net W completed If the permit Is forone bond mill dollars
(SIMBorleas.) WATER tIFATFR W/VENT/FL.GCTR ENERGY FEE Y_ N_
I certifyf.
that In the perrmance i f the work!.,which the,permit I,issued,
I shall not employ any person In any manner sou to become subject to the WATER 5YS1'FM/TREATING
Workers'Compensebon laws of California. Date PAID
C' Z Applicant NEw RESIDENTIAL PLMB. SQFT. Date Reml t#
Z Q NOTICE TO APPLICANT:If,after making this CenBlcke,of Exemption,you
should become,subject to the Workers'Compensation providers,of the Labor TOTAL:
C N Code,you at foot hwlth comply with such provbens or this permit shall be BUILDING CC demand revoked.
Wmavo
— CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there Is a construction lendingagency forthe perform ELECTRIC FEE
7 Z anee oflhework forwhlch this permit is Lssued(Sec.3097,Civ.C.) TOTAL:
U O lander•Name PLUMBING FEE
r Lroder.Address QTY. MECHANICAL PERMIT FEE
�, tion MECHANICAL FEE
0W omet.I agtlhademplywthisappllntiondmurand te tordinacesahatthe above dgate laws
M nelaIsctinglo agree tommtrumimalldtyandmuntyordinanma.tNe..laws PERMIT ISSUANCE FEES PAID: ra
} cityt peer upont ronsuudlogioned peoptrtyor Inspection
Vvzs
(_ Z city agree
to theabodemenBon it propertymr WpMen purpose. ALTER OR ADD TO MUCH. Dale Rttcipt#
(We)agree to Jude, encs,mks and keep harmless the City of Cupertea
U
against liabilities,Judgments,mks and expenses which may In any way accrue AIR HANDLING UNIT Q01(,000 CFM) SUBTOTA '
against said City inmsuenmoft.hentgflhis�}PJI_IF.
� MR HANDLING UNIT(OVER IO00CFM) CONSTRUCTION TAXMw � 11
'Ignature or pu=ant/Con actor IDate FXHAUS r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS MSCLOSURE
Will the applicant or future building occupant store or handle hazardous I MATING UNIT(TO IDQ000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the —
Heahh and Safety Code Section 25532(.)7 HFA7ING UMT(OVER 100,000 BTU) TOTAL:
❑Yes 1 l No
Will the applicant or uturc bdlding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSL' NCFUDATE /
which emit hazardous air contaminants as defined by the Bay Area Air
. Qua lily M.nsgemout Dist ndT BORER-COMP PHP OR 100,000 BTU) /
Yea No p� V 1991
have,mad the haza .us nutenals requirements under Chapter 6.95 of BORFR ER-COMP lO3,000N
B ) 1d0 4
the California Health&SafetyCode,Sections 25505,25533 and 2551. I .
understand that if the building doesnot currently have a tenant,that it is my NEWRESIDENUALMECH. SQ.iT.
rmponsibility to notify the occupant M the rrquircmenta which must br met CITY OF QUreH f INU
prior to Issuance of a Certificate of Occupancy.
Owner or authonred agent Date TOTAL: ISSUED BY.
a �
OFFICE COPY