22271 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT-PEN ONLY
Building Project Identification - '" - PERMIT NO.
Building Address: . - LGG 2 2^7 1
So . -sioKez. ita-12-
caner ams: one:
. A
nJ Cov/ J it)o - CITYOFCUPERTINO-BUILDINGDIVISION / /
Contradnr6
9 Name: .).LIe.No: APPLICATION I PERMIT
Amhllect/Engineer.
BUILDING-ELECTRICAL - COPLUMBINGMECHANICAL CATEGORY NTROL#
LkNo
�i . .
fiQ as trTY ELE(C'TRIC PEBMFTiIhti " �s �,,4t; oaq et,BU1LDING'PERMIT INFO, ' 'n'
C�Address: PERMITISSUANCE• .� QD (�I ❑ ❑ .
LICENSED CONTRACTOR'S DECLARATION
Ihereb e((Irm that lam L'cnsed under 'salons a(Cha erg commenc/" APPLIANCFS.RESIDENLAL TOB DE HLMON
Ingwith SeRlon 7000)of Dlvlslon3 o(the Businessand Profasdone Code,and my' -
licenx Is In full force and died. PANFdS
LlcenseChss Lic.N
Date Contractor IM TO 2QQAhIp5
ARCHITECTS DECLARATION 2014000AMI5
02. l understand my phroshallbe used as public records. OVER1000AMPS FLOOR AREA S/SQ.FT.
PqqP� CO q
E z(0 Licensed ProfessionalI
-• SIGNS ELECTRICAL Pee t - rqlL Z
<QQQ Q w License
DECLARATION
a�l SPECIAL CIl2CUIT/MI
.7a mn
yI' Iherebyaffithat lam exempt fromthe Contractor's LlcenLaw for the : •
p following reason.(Section 7031.5,Business and Professions Code:Any city or
OZt=. 'TEMP.METER OR POLE IN .
O� oaantywhiciftcture montoIspecance,mroreclum t the
eaprovent for.lsh,orrepairmito
g anystructure pritatcmmtthat a Is also sed portheapp the forsuchpemdt a POWER DEVICES .
65 �'
file..signed statement that he la licensed pursuant it the ion 7"1 of the - -
3� Contractor's uaffice Low(CMsslon Cmmmendng e6a as thinefofrarsd `
OCi SWIMMING POOL ELECTRIC '
sion3ofthe Business and Professloru Code)orthat hell ezemptthercfromand VALUATIO D
Q 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET&SWITCHESHXTURES - (] �.
p applinnt(ora permit subjects the applicant to a civil penalty of not more than s S Y;7,
five hundred a.owner
of the pr. SQ,FT. SIORI: TYPE CONSTRUCTION
NEW RESIDENTIAL ELECTR
as owner of the properly,or he employes with wage a there sole _
compensation,will do the Business and kand thnlCode:Thure Contraot ndedo License
ed for
Law
O saledoe(See 7044,to Business and f property
Code:The Contractors License Law
$ don net
ssuchtoan ownerofprough who W[Ids
mporimpmvnted turner,that such
OCC.CROUP RFS.UNITS
EE
who donsuchworkhlmsen edorough Msowaeered .It,ho evertheb building
or
improvement Issoldare lmendneyear kempletion theoweveglheerwill have TOTAL: +3 '
improvement bwid whhlnoneyeara(completion,theowner-WOderwW have
tF rden of proving that he did not build or Improve for purpose ofsale.). QTY; ;11"i" ',PLUMBING PERMIT_w FEC'{!`
FLOOD TANS MIN�1,as owner of the property,am exclusively contracting with-1- i PE4MITISSUANCE '
contractors to constrict the project(Sec.704A Business and Professions,Code:
The Contractor's License law don net apply to an owner of property who ALTER-DRAIN&VENC WATER(EA)
Wilds or improves thereon,and who com -
rade-for such pvjmU with a , ,a"'; .,
mpJpaOur(.)Ilnnxd pursuant to the Contractor's License Law,
[am exe un Sec B&P C for this reason - BACK FLOW PROTECT.DEVICE' 'II .'t#i ''j-t .FSU OUTSIDE EELS
- DRAINS FLOOR ROOF,ARCA,CONU. SANITARY Y . N•_
® Owner OR KMDate RECEIPT p
AN MPENSATION DECLARATION �.�S�.�P SCHCOLTAX Y
711[hereby a(flrm that I ave a cert!l of consent to sneure,ora RECE1N X
certificate o(Workere'C mperwtlon lnuumrance oracertlfled copy pytthereof(Sec.
3500,Lab C) GAS EA.SYSTEM-I WCAOUTLETS PARK FEE Y N
Po11cyX - GAS EA.SYSTEM-OVER4(EA), RECEBxT#
Com any -I BUI LDING DI VI SION FE CS
FCertified copy Is hereby thMGREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE 4[
-
F1 Certified copy Is filed with thee city
y inspection division. 3
CERTIFICATE OF ILCEMPHON FROM WORKERS" GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XM)F'C., - Date RCCCI I#
(Thlssectlon need not be completed lithe permit isfor one hundred dollars
(SI00)or less.) WATEICHEATERW/VENC/ELDCTR ENERGY FEE Y N
I.Aifythat in the performance of the.ark(orwhlch this pe.it i,Was,d,
I shall not employ any person In any manner n as to become subject m the WATER SYSTEM/TREATING
Workens Compensation lawsof California. Date PAID l
Z2 NOTICE NEW RESIDENTIAL PLMB.__SQ.WT. Date Recei t#
NOTICETOxe..bpt to the
orlefter maklompesationng this ProcatevI xempdon,you
should you
mmcaubjhwith comply
Work en'Comprewisinprovbiomrmit s Lab be + TOTAL: s�
LU N deemed revoked.
must forthwith comply wllh auchprovlalors,arthis permit shall be BUILDING 0
•� j. deemedrevoked. '
aCONSTRUCTION LENDING AGENCY - / SEISMIC FEE s 9
I herebyafflrmthat there is a construction lending agency for the perform ELECTRIC FEE
Zance of the work!or which this permit bLsaaed(Sec.3097,CIv.C.) r TOTAL: ��•� '.
U O Lenders Name PLUMBING FEE
ly -- Lender.Address Qr4. ;� '„MECHAIVICAL',PERMIT; ,t,FEE+,t MECHANICAL FEC
OW Icertlfythat l haveread thisappliationand statethatthe above information ,
1 lammed.I agreeto comply with all city and county ordinances and state laws- PERMIT ISSUANCE FEES PAID:
>_ IL relating to building construction,and herebyauthorlaerepresentativesofthbt
'f. cityto enter upon the above-mentioned property for,impection purposes. ALTER OR ADDTOMECH.
a (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
'V against BabiIties jidBrrent{cone and expenses which may In anyway accrue AIR HANDLING UMT.(C010,006 CFM) - SUBTOTAL:
against sal By, m enno(thegraningofthi.pemdt. - , CONSTRUCTION TAX .
_ AIR HANDLING UNIT(OVER 10,000 CFM)
"K� Si reof Applic' /Contractor . Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCLOSURE
Will thea B turfuture building occupant store or hand le hazardous HEATING UNIT ITO 100,000 BTU) Date RCCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Ilealth and Saldy Cod,Section 75537(.)7HEATING UNIT(OVER 100,000 BTU) TOTAL:' 3a
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminant ads defined by the Bay Arca Air - t' Al il+41
oftQuality Management Disco? BOILER-COMP OHP OR 100,000 BM
❑ Yes' . . ❑No r cur,
Ihave rndthe hazallous matcrialirequlrcmenb under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) JIjjt' 7 7 (ay{, ,.
the California Health&Safety Code,Sections 75505,25533'and 75534.I VlC �a i C
undeniand that ifthe building does not currently have a tenant,that it is my NEWRESIDENTIALMEOL SQFT
responsibility to notify the occupant of the requlremcnts which most be met - Q11141o4i M1�®•
prior to Issuance ofa Certificate of Occupancy.
Owner or authorized agentUale 4rCV�',
- TOTAL: ISSUEDBY: I
,.OFFICE COPY
S )
CZs
!rP4
a
10
�
Ob \
� ot,
o '
Rb
rn
c
lI �
t
a31 acsgo
O Oo O Axa y O �
0 1
w