22858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruildln Pso ect Identification - PERMIT NO.
`ld n ,s. s�� ti� .� 4,s ,� �-���� 22858
wMor; rre: h, " ane: A
a jcey � �Zb�� CITY OP CUPERTTN66UILDING DIVISION &,—//^ 7 /
Contractors Name: LIc.No: APPLICATION / PERMIT
Architect/Engineer. Lk.No: BUILDINGELECTRICALPLUMBINC-MECPUNICAL CATEGORY CONTROL M
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMIT ISSUANCE ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(commenc. APPLIANCESRESIDENI'IAL JOB DESCIiB9lON
ingwithSMlon 7001gof DiWslon3ofthe Busimssand ProfauloneC cle,andir
licenselslnfullforceandeffecL, PANELS
Lica..Clam Lic.tl
Date Contractor UP TO 20OAbTS
ARCHITECTS DECLARATION 201-10DUAMP3
qvrel$ I understand my plans shall be used a,public records. OVER I ODO AMPS SQ.Fr.modit AREA $/SQ.FT.
DDECLARATION IN
L�I=j Licensed Profeatlooal SIGNS ELECTRICAL
LED D
OWNER-BUILDER SI'ECULCIRCIAT/MISC
7 p., 3 IherebyaffirrntOWNEexempt ER orsLicense lawfor the
oo following reason.(Section 7Q11.5,Business and Professions Code:An cityor OW PUT
Ft"'ty county which requima permitto comtmct,alter,Improve,demolish,orreair TEMP.METER OR POLE INST. , O
q� ❑ 2E
anystmclure prlortolts ance,alsorequlmtheappbmnt forsuch permit to 2
rx4 POWER DEVICES
file a signed statement that he it;licensed pursuant to the provisions of the
3u' Contractor's License Law(Chapter9(commencingwith Section 7000)of Divi- SWB.TMING IDOL FIECTRIC
OS sion3a(the Busineaemd Prdf.I..Code)o,thathelaemmptthemfmmand YALDATfM
< the basis for the alleged exemption. Any violation of Section 7031.5 by any 0[TR.CiSSWTTC]{FSITXT[IRFS
applicant fora permit subjects the applicant to a civil penalty of re
not mothan
five hundred dollars(5500). NEW RESIDENTIAL ELECTR
�m QI,as owner of the pmperty,or my employees with wages as their sale �'�' STORIES TYPE CONSTRUCTION'
compensation,will do the work and the structure b not Intended or offered for
Osaie(Sns70K Businessind Professions Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or Improves thereon,and OCC,CROUIs RFS.UNITS
doessuch workms
hielf orthrough Malmo employees,provided that such
improvements arc not Intended mattered for sale.If,hcwevcq thebuliding or TOTAL:
improvement Mold within oneyearofcompleBon,the owner-builderwlll have
t rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD%ANE APN
4 as owner of the property,am exclusively contracting with limnsed
contractual to construct the project(Sec.7614,Business a ad Profession Code: PERMIT ISSUANCE
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN&VFM-WATER(FA)
Wilds or Improves thereon,and who contracts for such ptojecta with a
m,BlfactoRs)licensed pursuant to the Contractors Lianas Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_l I am exempt under Sec. B k P C for this reason :E
Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
-� Date RFOFR�.=
WORKMAN'COMPENSATIONDECLARATION FL%Tl7RES 17:R.I'RNs SCHOOLTAX Y— N
❑i hereby fflorke that I have o l...to of consent m pythn Are,ors RECEIPT X
mrti(Icab C.Workeri Campenationlmurana ora artlfied copy themof(See. GAS FA.SYSTEM-1 INCA poli lab C.) PARK FEE Y_ N
CM. p GAS EA.SYSTEM-OVER RIiCE1PPM
C°^' ^Y B UILDING DI VI SION FOES
Certified copy b hereby filed
the ed
city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy la filed with the city inspection division.
CERTIFICATE OF FX MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2TOFr Date Rilmi of
Rh.e section need nM be completed lithe permit V(Drone hundred dollars
($i00)otify(h WATER HATER W/VENT/ELECm ENERGY FEE Y N
(artily that In the performanao(the work far which this permitbIssued, —
I shag not emp oy any person In any manner so as to bee o'7P ct WATER SYSIAt/,IRFA,DNG
WorkersApplicant mat ion LaIA o(GII( i .Date Exe PAID
O Z NOTICRt //
Z O NoncE PLP T:IQafter making thh em teo(Exemption,you NEW RESIDENTIAL PLMB._SQFT. Daft Reeei tri
should W me subject to the Workan''Compematlon provisions of the Labor TOTAL:
N Cale,you must f^rthwith comply with such provision orthis permit shall be
deemed revoked.
Lj G CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL G
. Thereby orkf.ratthereisacomtmctlond(Sec. agency Civ. lhe perform ELECTRIC FEE
()Q Z Lenderthe work!or which thLs perMtbesued(Sec.3097,Civ,C.) TOTAL. PLUMBING FEE
O Lender'.Name '
LL.
F Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerUfythatl haveread this application and esawthattheaboveinformatlon
V cnnect.l agree to comply with all city and county ordinances and state lawn PERMITISSUANCE FEES PAID:
Nrelating to building construction,and herebyauthorizerepresentativeso(this O /..
Z city to enter upon the abovnmentloned property forimpectlon purposes. ALTER OR ADD TO MECH.
— (We)agree tosave,indemnify an d keep harmless the City of Cupertino Date eCejPt((
against liabilities,judgments,costsande penseswhlchenaylnanywayaccme AIR HANDLING UNIT(TO 10,000 CEM)
;—t sai tyro anu.gollh1 pe t SUBTOTAL:
G /O/ p AIRHANDWNG UNIT(OVERIg000CPM) CONSTRUCTION TAX
Ignatum of Appcant/Contractor ! / Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building'occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) Date Reed tk
material as defined by the CupppyypyNNno Municipal CWe,Chapter 9.17,and the -
HeallhandSafetyCod 75532(a)7 HEATING UNIT(OVER 10,000 BTU) TOTAL:
Yes No
Illthe appllcanla lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which soul hazardous air cony�al11mots as defiwd by the Bay Area Air Pill
Quality Management Di BOILER-COMP pPIP OR 100,000 BTU) /
IT—IhaYes No
vcread the hazy our Code,Sections
25505,25533 and
Chapter.1 of BOPLFR-CONP(OVIR 100,000 BTU) lv
thecrstannia ResilebSafety Code, otcurrntly h ve atead255k.! 6e�/ j '� X9,9und7
rimpontandtlut Ifthe notify
the oa, don not currently haves tenant,that it is mybe
NEW RESIDENTIAL MECFI. SQ.Ff.
Fri has
lona aCerfi occo ant o(the Ne is which rtwst be rtaM ('1�/sa rxsa(( �PPpp
Fri oivua aGrt10 t olOttvpa // �Y�Cuyss
l a��
ner or authorized sIont Daze
TOTAL.: ISSUE
OFFICE COPY