22413 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - - - PERMIT NO.
Buld ing Add rens:
2� ss� ,d�roioZ 22413
wnera ..: ane: APPLICAII.NbUOM111ALUAII,
GCITY OF CUPERTIN4qI
6UILDING DIVISION '7 _ ' _ p�
fYG l'''�/y �-•��
Ct'ttorNamAPPLICATION / PE RMIT / C
• vge e � Ic.Inti:'
4y BUILDING.ELFCTRICAL-PLUMBING-MECIiANICAL CATEGORYCONCROLX
Architect/Engineer. Lie.No:
36TY ,',4ECTRICPERMIT'',''�' FEB � BUILDING PERMIT INFO
Addrcss: S.73.4� PERMITISSUANCE• ],Q ❑ 17LICENSED CONTRACTOR'S DECLARATION "
Ihereb affirm that l am licensed under provisions of Cha er9(commenc- APPLIANCFSRESIDENTIAl, '
Y P on ,JOB DESCRIPTION
•Ingwllh5ectlon 7000)of DlWsion3ofthe Buslneseand Pro(eseionsCode,and my '- '
license bin full 1prFe anELG X `s�j�A„� PANELS �•
License Class G!O �Oaf"AI'l! �t t��
Date Cantnctor Q`•
ARCHITECTS DECLARATION 201-I000 AMPS
OZ I underatand my plain shall be used as public reards. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
I)`
C Licensed Profemlonal
SIGNS ELECTRICAL
U
15 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
L., 7 (hereby affirm that l am exempt fromthe Cornmeto/s License Law for the '
IIS Z po . fo0owin reason.(Section 7031.5 Business and Pro(essbn.Code.Any city orOZ
TEMP.METER ORPOLE INSi.
F� countywhicF mrylroapermittoromtact,alter,lmprove,demaWh,orrepalr ,
qq'' Q
anystmarrom prlorto Its Issuance,also raqulreatheappBant forsuch permit to l POWER DEVICES SQ
15� U Ole a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Ch prter9(rommenctng with Section 7000)of Divi- SWIMMING POOL ELECfRIC VALUATION
OJ slon3ofthe B..oa...dProfessloro Code)arthatheisexempttherefromand< II n•] the basis for the alleged exemption. Any violation of Section 7031.5 by any Un TSSW(TCHESFIXTURES
applicant fora permit subjects the applicant to a civil penalty of fiat more the
five hundred dollars($5001. NEW RESIDRNUAL ELECTR SQ.FT.
�n
F1 1,as owner of the property,or my employees with wages as their sole STORIES' TYI'G CONSTRUCTION
f compensation,wlll clothe wor"rol the structure Is not intended or offered for
O sale,5ee7044,Bu.I..ad Professions Cods:The Cmdracte.LicenseLaw
�$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP - RES.UNITS
EE who does suchwork himself or through his awn employees,provided that such
Improvements are not Intended mattered tarsals.If,however,the bulldingor TOTAL:
improvement lssold withlnoneyearofcomplelion,theovter-bulMerwlll have -
trdennfpmving that he did not build or Improve for purpose of'sale.). QTY, �' ' ��"PLUMBING PERMIT;,' ( FEE'"
nL as owner of the property,am exclusively contracting with Ile oud FLOOD 7oNe APNPERMIT ISSUANCE
contractors to comaruct the project(Sec.7044 in
Busessand Profession Code:
3fie Contractor's Llmme law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
bulks or Improves thereon,and who contracts -for such p(ojects with a •a FEESUMMARY
,
tot et r0)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B k P C for this reason
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date ., RECEIIrI'p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCTIOOL TAX Y_N"
[31 hereby efflrm that I have a certificate of consent to self-insure,or RECEIPT X
certificate ofW.rkers Coropersatian lrauranceora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK EFF. Y N
38W,LbC.)
Policy X RECEIPT X
GAS EA.SYSTEM-OVER 4(EA)
` Com any BUILDING DI VISION FEES
�Cer00ed ropy ifiled with
the city
inspection division.
Is hereby te
Certdied ropy Is ciCREASE/INDUSIRL WASTE.INTERCEPTOR PLANC14ECK FEE
� ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM G.2WFf. Dale Recei lip
(Thlssecilon need not be completed tithe permit isforoM hundred dollars
(81 W)orlesh) WATER HEATER W/VENT/ELECTR ENERGY,FEE Y N
I certify that in the performance olthe work for which this permit l Isom,
I shat not employ a y person in any mane,m as t to th ATQt SYSI'FM/TREATING .
Workers'Com i wsa If .D e PAID
O Z Appll ant RESIDENTIALPLMB. SQ.FC. Date RCCCI ty
Z 0 NOTICE TO LICA f,after making this Certificate of
should became subject to the Workers'Campereatlon provisions of the Labor TOTAL:
N' Code,you most forthwith comply with such provisions orthis permit shall be
ccj dremed'revoked. BUIL12INc '•
LLI.a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a mrutructlon lending agency for the perform- ELEC'T'RIC FEE
M Z ance ofthe work for which this permit Is lsacd(Sec.3097,Civ.C.) 70TAL:
•U O lender's Name - PLUMBING FEE
LL lenders Addmes QFEE
MECHANICAUPERMIT'.'' MECHANICAL FEE
UIcedlfythatlhavemadthbappUcatlonandmatethattheabove Nformatlon
O WIscarrect.I agree to comply with all city and county ordinances and state laws PERMTTISSUANCE FEES PAID:
} a relating to building construction,and hereby authorize representatives ofthis
F N city to enter upon the above-mentioned property for WpMion purpose.. ALTER OR ADD TO MECH.
U (We)agree to.eve,Indemnify an d keep harmless the City of Cupertino Date Recei til
against liabilities,iod •fits,cost ndexpense.whlcheraylnanyweyacusre AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agair�s dCityl ence o(th ntlng of this permit AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
Sig reo Applicant/Contracto -------� EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE "
Will the applicant or Tatum building occupant store or handle hazardous HEATINCUMT(TO 100,000 BTU) Date Recei til'
_ material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —
Ilealthand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - - ' TOTAL
❑Yes , —INo
Will the appliesfi,Rium building occupant use equipment or devices VENA IATION FAN(SINCLE REMO) - ISSUANCE DATE.
which emit hazardous air rontandrants as defined by the Bay Area Air
Qua lily Management Dist rlct7 BOILER-COMP CIHP OR 100,0(10 BTI!) a �yai/
4 Yee 9 No
have read the bozo ou.materials requirements under Chapter 6.95 of BORER-COMP 100,000 RM
the California I lealth k Safety Code,Sections 25505,25533 and 25534. I {
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MSCI 1. 'SQ.r.7 ass
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. ryXaa
CW at.owto'.
Ownerar autharized a gent Date ISSIIEDBY_A-)
TOTAL:
OFFICE COPY