22896 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'mie#Identification PERMIT NO.
Building Address: 22896
0 4. S c�,V/c c .
sone# ace: one: pPT7TXr A
<L 4u 4('0 259' - 7 CITY OF CUPERTINO-BUILDING DIVISION /O -,2_e
Contra ace: Lic.N. APPLICATION / PERMIT L
Y,/ ..i4(^�7AT /�arY BI/V� �'cY. 620 ! • BUfLDING-E MnUCAT PLUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lic.No:
,QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITIZA'NICE ❑ ❑ }�j r1
LICENSED CONTR under provisions
�N ISI
I hereby licensed 3ofthe underrpessand mfe"ionsofChap1er e,mmrn MPLIANCESRESIDENTIAL JOB UE BI TION
IniSeniors 7000)ol Dl effect ofthe Budnessand ProfemeloneCode,acid my
L.license Is I.s ro .eta erre#, PANELS
uanmclamC�• uc.x 6'Zo342r
Date Contractor UP TO 2DO ANUS
ARCHITECTS DECLARATION 201-1000 AMPS
02, Licensed Professional SIGNS ELECTRICAL tI rr I understand my plane shall00 be used as public records. OVER 10AMPS - SQ.Fr.FLOOR AR $/SQ.FT
d ,
C LED
rNz U :
fn OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC P U T E R
io.., Iherebyaffl.that lam exempt from the Contractor's License law for the
OZ � following mason.(Section7011.5,Businewand Professions Code:Anyetyor TEMP Mh7MOR POLE INST.
C JF 11
P countywhichrequimapematlommtmM lter,lmpmve,demolbh,ormpair /
q'� 3 afile a signed statement that he nystruclurc prlorm its isauance,alsorequlresthe applicant for such Ferreira TE
R O b licensed pursuant to the provisions of the POWER DEVICES
6Q u, Contracto/s License Law(Chapter 9(commencing with Section 7000)of Dlvl-
Gn SWIMMING POOL ELECTRIC
elon3oflhe Bualncsaand Pro(esslora Cade)orthathels exempt lhere(romand VALUATION
6 the basisfor the allegsdexemption. Any violation of Se#ion 7031,5 by any OUTLETS-SWITCHES FIXTURES
applicant for a permit subjeetsthe applicant to a civil penalty of not more than
five hundred dollars(SM. NEW RESIDENTIALELECTR
Se
F-1 1,as owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPE CONSTRUCTION
compensation,will d o the work and the structure is not intended or offered for
Osale(Sec.70K Business and Professions Cade:The Contractors Lt..Law
$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RES,UNITS
who doesauch work himself orthrough his own employee.,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement Is sold within one year ofcomplellon,the owner-builderwlll have
tti5, ncla.of proving that he did not build or Improve for purpose of ask.). QTY, _ PLUMBING PERMIT FEE
LJ 1,as owner of the roe FLOOD TONE APN
p p #y,am exclusively Business
and
with licensed PERMIT ISSUANCE
coeContratocaatmethe project(Sec.70Kapply
Business and of
Code:
The Contractor's improves
esthereon,
License Law does not apply tct an owner p property who ALTER-DRAIN k VENT-WATER(EA)
Wilds o Improves thereon,and who macro#a for such p,okee with a ,.
�+jB.t{+noKglimpt under
to the Contractor's License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY'
I-„J[am exempt under Sec. B &P C for thio reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEIn x
WORKMAN COMPOSISATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-insure,or
FI%TUIRES PER TRAP SCHOOL TAX Y_ N—
certificate of Workers'Compensation Insurance ora artlfkd copythemof(Sec. RECER7 x
3800,Iab C.) GAS B.A.SYSTEM-1 INCAOUILIt � PARKFEE Y_ N_
Policy Y CAS EA.SYSTEM-0VER 4(EA) RFY;E x
Com y BUILDING DIVI SION FE ES
Ified copy b herebyfurnished:the cid: GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection dividon.
CERTIFICATE OF I7(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-&ANITARY-STORM EA200F1. Date Recei t#
(rhlasenlan need not he completed tithe pemNt b for one hundred dollars
(S10J)orly that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y _ N
I llnot that N the performancearsonIn any m worknner foras which become
eesrtdt b Issued,the —
I shag not employ any person in any manner n u to berome wbjee to the WATER SYSTEM/TREATING
Workere'Compeneatlon laws o(Callfomla.Date PAID
O Z NOTICAppilcaE NEW RESIDENTIAL PLMB. SQF7. Date Recel I#
Z O NOTICETO conedi APPLICANT: after making this Certificate of Exemption,you
Fshould bsmme mbjen to the Workem-Compensation provisima o(lhe Labor TOTAL:
VS Code,you roust forthwith comply with such provisions or this pemNt shall be
W j deemed revoked. BUG FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
.a e I hereby affirm that there is a construction lending agency for the perform, LECTRIG FEE
Z arcc.fthework rorwhIchthispxrmJt b Issued(See.3097,Civ,C.) TOTAL:
U O Lenders Name I PLUMBING FEE
LL ~ Lendce's Address QTY. , MECHANICAL PERMIT FEE. MECHANICAL FEE
O W Imotlfy that]haveread this application and date that theabove Information
Ice correct.I agree EE
to comply with all city and county ordinances and date laws PERMIT ISSUANCE ' FS PAID
G :
IL relating to building comtmeion,and hereby submiam representatives ofthls -
F Z city to enter upon the above-mentioned property roe inspection purposes. ALTERORADDTOMECH. Date Recel t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino P
agalrut liabilities,judgment,mdeand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalrat said City In mnmryuence o(the #ting of thio permit t AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
•�� � o-••—. /o/e 2rs
Signature of Applicant/Contractor Date EXHAUS"r HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum bufldingoaapant store or handle hazardous HEATING UNIT(TO I OD,OOD BTU)
material as defined by the Cupertino Municipal Code,Chapter 93Z andthe Date Recei t#
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,OOD BTU)
n Yes No
i troll appllantor tumbuildingnants as
nd by the BayequipmentArea device VENTILATION PAN(SINGLE RESID) ISS(. TE
whichtrollair rotaMnants as defined by the flay Area Air
allay Management District? BOILER-COMP DFIPDR 100,000 BTU)
Vet n❑No
have read the travrdous materials requlrcmenta underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU).
the California Health A Safety Codi,Sections 25505,25533 and 25534. I (y�ppa4�
understand that tithe
notify
uilding the..poet not
erequcurrently
erents which
that It iset NEW RESIDENTIALMECH. SQ.Fr.
responsibility Issuance
notifytheic to of oftherequirementswhich must be met
prior to issuance o(a Certificate ofOcrnpanry.
Owner or authorized agent Date ISSUED BY `r•��' 'mss
TOTAL:
OFFICE COPY