22666 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project denanration PERMIT NO.
Building Address: 22666 r r
aoyaS .5 u15 0rio C�uPERriNo 9501 G N6 o
nets ante: APPLICA - A A
✓ oLSS JJ 7 f V CITY OF CUPERTINO-BUILDING DIVISION
410 Centrane:sName:�'^/ LIc.No, APPLICATION /PERMIT
516 j311G�IJ BUILDINGELECT)UCA PLUMBINGMECFIAMCAL CATEGORY CONTROL
Archect/ gincer Lk.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 1 PERh4Ti55UANCE l Lj BLDG fie 1�1 ❑ ❑
,
LICENSED CONTRACTOR'S DECLARATION
u BLfir � 1
I that I am Rcensedunder provisions.dPm Chapter9(rommenc APPLIANCESRESIDENTIAL JOB DESCRUMON
IngwlthSm1an7000)of Dlvlslon3 afthe Buslassand ProtesalonaCode,and my ,�((''2� �-.p' ' 1
license i°in fail force and effect. PANELS R, �/ eRT e
License Cbm Llnp
Date Contractor 1G�C10'
ARCHITECTS DECLARATION 201-1000 AM
oz I understand my plans shall be used as public record s. OVER IOW I5 wS�.FT. COR"FA
NUO '\V�
B Licensed Professi"nal SIGNS ELECiRICA
z
6 OWNER-BUILDER DECLARATION SPECIALCI4CUIT
HER
Ihercby affirm that l am exempt from the Contractor's License Law fm the
z O 'a followin reason.(Semon 7031.5,Business and Professions Code:An ri or t
�zi"'t9i countywhlch requbeaa penNt taconstaa,ilter,lmprove,dennlish,or repair TEMP.M � OR POL
44 anyatructm,prior to its tcwance,aLw requires theapplicam for such permit to
6 file a signed statement that he is licensed pursuant to the provisions of the POWER DEVI
O�
Contractors License (ChapterLaw 9(commencin with Section 7000)of Divi-
OS "a oftheeuainensand Profelons Cade)"rthagheisexempttherc(romand SWA4hINC POOL ELECTRIC VALUATION
Y1_ the basin for the alleged exemption. Any violation of Section 7031.5 by any 2 OUTLETS-SWITCHES-FIXTURES f
o^ applicant fora permit subjects the applicant to a civil penalty of not more than
a ��.�
c. five r`d net of thdollars eme NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRI/C'1']ON
�n property,or my employees with wages as their sole
pematlon,wlfldo the work and the structure is not intended or offered for
kJ O C a(Sec.7046,Business and Fruitage.Code:The Conhanor°License Law
fil $ d es not apply to an owner of property who builds or improves thereon,and
who dare suchwork himself ne through his own employees,provided that such OCC.GROUP RES,UNITS
Impmermants are not intended oroRered for sale.If,however,lhebuilding oe TOTAL: TQW
improvement is sold within oneyearofcompletim,the owner-bullderwlll have
th rden of proving that he did am Wild or impmve for purpose of Bala.). QTY. PLUMBING PERMIT FEE ELODDZONE APN
4 as owner of the property,am exclusively contracting with licensed
ronuacton to construct the project(See 7064,Business and Professlors,Code: PERMIT ISSUANCE
The Contractors License Law docs not apply to an owner of property who ALTER-DRAIN&VENT-WATER
or Improve° ts thereon,and who contracts for such ptojewith a
yyn�actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sm B&P C for this reason
Avner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
WORKMANCOMRECEIPT NPENSATIONDECLARATION iRAI'
[:]I hereby affirm thatceNaFIXTURES PER SCHOOLTAX Y N
.l have a n
te of consent to self-Insure,or RECEIPT M
cortiflcete ofWorkers'Compenaationlnsuranm ora mrtified copy thereof(Sac. GASFASYSTEMIIJC40UILETS _
3800,LabC.) PARK FEE Y N
Policy p RECEIPT p
Com y GAS F.A.SYSITM-0VER4(EA) BUILDING DI VISION FEES
Cdied copy is hercbytumAS
Candied copy V tiled with theecity
ty Inspection division. GREE/INOUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SE'WF.R SANHARY STORM EA 200FT Date Re021 t#
(Thi°action need seabe completed lithe permit is(Drone hundred dollars
($1W) .)
(certrtifyifyt WATER HEATER W/VENT/ ENERGY FEE Y N
that In the performance of the work for which this permit is issued, ELECTR —
I shall not employ any person in any manner an u to became subject to the WATER SYSTEM/TRFAIING
Workers Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT,If,after making this Cenlicateof Exemprian,you NEW RESIDENTIAL PLMB. SQFL Date Recei t#
Fshould becomeaubject to the Workers'Compensation provisions of the Labor TOTAL:
WN Code,you=at forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILQING IT-E i
a C CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hercbyaffirmuctl
thattherc isamnsuon iendingagency forlhe perform ELECTRIC FEE
O ance ofthe work fmwhieh this parmR is Issued(Sec.3097,Civ.C.) TOTAL:
U Land"aN°"" PLUMBING FEE
LL Lender§Address QTY. MECHANICAL PERMIT FEE ;FEES
CHANICAL FEE
O W Icenitythatl have read thisappBalfon and matethatthe above information
Is Correct.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE PAID:
relating to building constructioq and hereby authorize repreaentaHves of thisZcity to enter a Pon the abovo-mentimed property for Wpection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#againstlubN dgmenbcome and expenses which may lo saywayaonne AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:againstaai i n n emofthegrsnting ofthis PermitAIR HANDLING UNIT(OVER IO,000CFM) STRUCTION TAX
u pito /C t n.r Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Llwill the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Flcilth and Safety Code Section25532(a)2 HEATING UNIT(OVER 100,000 BTU) Z
Q Yes M No TOTAL:
Willtheapplicant orfuturebclldingmcupant useequipment ordevices VENTILATION IAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous air contaminants as dented by the Bay Area Air
QuL�'i
alitMstagement DiYs n�sWINo BOILER-COMP OHP OR 100,0(10 BTU)
e read the haza S1cr materials rcqulrementsunder Chapter 6.95 of BOILER-COMP(OVLII1W,000 BIL)
ornia Health&Safety Code,Sections 25505,25533 and 25534. Ind that i(the building does not currently havealenanL that itismy NEWRESIDENTIALMECH. SQFT.
bility to natty the occupant of the requirements which must be mm SEaP
nuanreofaCerviBcateofOccupancy,
r authorized agent Date1[l0
TOTAL: ISSUED BY:
OFFICE COPY