22314 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B°Ra"g : 22314
2001111 �rn��r prLtyG CvP.
nersante: A A A
E COLL.1.4KIgB2 2S7 10Z0 CITY OF CUPERTINO-BUILDING DIVISION �^ / C7 /
Contractor's No.: Lie.No: APPLICATION I PERMIT —0
Architect/EnBfee r r. LkBUILDING-ELECTRICALPLUMBING-MIOHANICAL CATEGORY CONTROL#
.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERh9TISSUANCE QIf ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(ammore. APPLIANCES RESIDENTIAL JOB DESCxu N
tngwlth5 dion7000)of Div61an3ofthc$usineasand PmfesslonsCude,and my
license 1.1.full force and effect. PANES
License Class LION (l/
Date Contractor /14 UP TO 200AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
p2. (understand myplareshabeused as publicsemrds. OVER 1000 AMPS SQ.FT.FLOORA $/SQ.FI'.
�qqp± O
E Licensed Professional SIGNS ELECTRICAL q E D
<<�G OWNER-BUILDER DECLARATIONI hereby —( SPECIAL CIRCUIT/MLSC L
ntywhichremthatl em tW.t tro he Contractors demiicense h,ormaw for the
following reason.(Semon 70315,Business and Profession Code:Any sty or
Fg� countywhichInformIts permit ,almonuireatheaprovgdemouch permit
TEMP.ME77RORPOLE INST.
any nrudvreptlortoits haance,atsore d Emosuam t oche forsuchperfNt e
AMPUTE I
file a signed statement that M V licensed pursuant to the proWion of the I'04VF.R DEVICES
�3w Contractor.License Law(Chapter 9(rommencingwith Section 7000)ofDivi- gWATh9NGPOOLELECTRC TE 713
F,�OS smn3ofthe Busmessand Professio.Code)orthathe6e.mpttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any JI
p+u`�OG OI71LE]SSWfTC}IESFIXI'URES
applicant fora permit subjects the applicant to a ciWm
l penaRyof not ore than
tc: fki+ five hundred dollars(SSM. NEW RESIDENTIAL ELECTR
(n �as owner ofthe property,or my employees with wages as their sole cSQ}T, STORIES TYPECONSTRUCTION
mmpenation,will do the work and the structure is not intended or offered for
Osale(Sec 7044,Business and Profession Code:The Contractor's License Law
�3S does onapply toan owner d property who builds or improves thereon,and OCC.GROUP RFS.UNITES
Improvements
h.rkhi.1r'.rth.ghhisownemploye.,providMthatach
Improvements arc not Intended oroffered forsale.If,howeveq thebullding or TOTAL:
Improvement bsold withinoneyearofcompldiogtheowner-Wilderw111 have
th [rden of proving that he did not Il
build or improve for purpose ofsals.). QTY, PLUMBING PERMIT FEE OOD2ONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the pm*d(Sec.7644,Business and Profession Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VEM'-WATER(EA)
Wilds or Improv.thereon,and who contnm foe such ptoj to with a
Qmractor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
r[�p am.empt un Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date - DRAINS FLOOR ROOF,AREA,COND. SANITARY V N_
• RECEIPT'#
ORICS COMPENSATION DECLARATION F1X'NRES I'FR TRAP SCHOOLTAX Y_ N
❑1 here affimn that I have a certificate of consent to aeB-snare,ora RECEIPT M
certificammWorkers'Compenationlmurnceoracediftedmpythereof(S . GAS EA.SYSTEM-1 ING40[TIT,ETS
3800,UbC.) PARK FEE Y N
Policy# RECEIPT M
Co any GAS EA)
EA.SYSTEM-OVER 4(
ECe,ti ied copy Is hereby furnished. BUILDING DIVISION FEES
❑Certified mpyb filed with the city lnpection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(TFisxctlon need not becompleted lithe pernot lsforom hundred dollar SEWER-SANITARY-STORM EA.200FT. Date Receipt#
($100)or less.) WATER HEATER W/VIM/EECTR ENERGY FEE Y N
I ll not that in employ
an person
in an the work sfor
as to become
permit
subE is Issued N—
I WII not employ any person in any manner a.to become abject to the WATER SYSTEM/TREATING
Worker'Compensation laws o(Califomla.Date PAID
Z Z Applicant
Z O NOTICE TO APPLICANT.If,after making this CertNoteof Exemption,you NEW RESIDENTIAL PLMB. SQ}7, Date RcC i t#
Fshould became subject to the Workers'Compenatlan provision of the Labor TOTAL:
N Code,you most fort hwith comply with such proWbns or this permit shall be
W > deemed revoked. BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
hereby afllrmthat there Is a construction lending agency for the perform- ELECTRIC FEE
n Z anceofthe work for whichthis permit is blued(Sea.3(197,Civ.C.) TOTAL:
OO Lander.Name PLUMBING FEE
LLL) Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O Irndifythat l haveread thisapplicatlonaod atatethattheabove Information
IL oComet.Iagreeto comply with all city and county ordinances and mate laws PERMI'TISSUANCE FEES PAID:
} W relating to building contraction,and herebysuthorirerepresomadv.ofthls
Z city to enter upon theabove-mentioned property for Inspection purposes, ALTER OR ADD TO MECH.
— (We)agree m save,Indemnity an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,costs and expenses which may In anywayaceme AIR HANDLING UNIT(TO Ill"CFM) —SUBTOTAL:—R.I. said City in fthegntmi.galthh,permit.
�? � MR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Signtafre ofA ran/Contractor Data E(HAUS"f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutom 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 Reeei t#
Fleelih and Safety Code Section 755..a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
❑ Yes �]No
Will the applicant or(umrcbuilding ompant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$U CE DATE
which emit hazardous air comamtrunb as de0ned by the Bay Arca Air ppi�ps
Quality Management District? BOILER-COMP OHP OR]WDC*BTT) {�
Yea ❑❑No
have read the hararano materials requirements under Chapter 6.95 of BOTLIR-COMP(OVER 100,000 BTU)40 ���� ) /� 1 1
the California Health h Safety Code,Section 25505,2:5533 and 25534.1 Fs V M
understand that lithe building does not currently have a tenant,that it is my NLWRESIDENTIALMECH. SQFT.
respmxsibility to notify the occupant of the requirements which must be met
prior to Issuance a a Certificate of Occupancy. (silty W of(Oss ptim
Owner or authorised agent Date TOTAL: ISSUED BY: yV— �d� v r f
F ICE COPY