22885 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
zsloo vik47 22885
wrens ante: Q � APPLICATION 7 DATE
'� R ^ W / /tlo CITY OF CUPERTIN0.6UILDING DIVISION /O /
Cmo does Name: _ Lic.No: APPLICATION I /CJ PERMIT
_r2)aL)6zA-5 l f.JF/G�•�� .8 (4)0671 BUILDING-ELECTMCAI PLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Englone, Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1 PERMITISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provblonsof Chapwr9(orn... APPLIANCESRMDENFIAL JOB DESCFTION/
ingwithilection70o0)a(DINMon3ohhe Buslnessand ProfnslonsCode,and my
Times Is in full force and d(ect. PONTIS
LlanseClam Lie N
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
1Q+�NCOZ I understand my plane shall be used as publicremrds. OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ,FT.
Licensed Professionsl SIGNS ELECTRICAL 9
«<< LG7 OWNER-BUILDER DECLARATION �` '�
z� 3 hercbyaffimthatIamexempt from the ContranolsLicense Law for the SPECGLCRCIRT/MLSC U
po following rcasan.(Section 70)1.5,Business and Professions Code:My city or
2 I:. TEMP.MEM OR POLE INSr. ,
P T
� county which inquiries permit tpmnstmct,alter improve,demolbh,orrcpair /
anystructure prior to its beuance,alsorequlre,the applicanHorsuch pemdtto OWER DEVICES D E
O 6 file a signed statement that he he Boeraed pursuant to the provisions of the
>u, ContiaROls License Trw(Chapwr9(mmmendngwith Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUATION
VI sion3 ofthe Business and ProfesslonsCode)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
«
applinset fora permit subjects the applicant to a civil penalty of not monothan OUTLEISSWITCHESFIXTURFS 2.S
five hundred dollars MM. NEW RESIDENTIAL ELECTR SQFP. STORIES TYPE CONSTRICTION
❑1,as owner of the pmperty,or my employees with wages as their sok
�7a compensa/Ion,wllldothework andm
therodure is not intendedor offered for
,N O ssIn(Sete 7044,Business and Professions Code:The Contractors Llmnse Taw
Myroves$ does not apply to an owner of property who build,or Impthereon,and OCC GROUT' RFS.UMTS
whodoes suchwork himself or through his own employees,provided that such
Improvempnb are not Intended proffered for We.If,however,thebuilding or TOTAI.
improvement b sold within omyearofcompleiom the owner-WflderwBl have
14L¢urdenofpmving that he did not build or improve forpurµne visits.). QTY. PLUMBING PERMIT FEE
LI FLOOD ZONE APN
L as owner t the property,am exclusively Business
and
with licensed PERMITISSUANCE )
TheconCotoretomnstmctthewdoeproject(Sec app] to
and Professions Code: e.5
The Coor Impoam,the Few does ria apply tct an owner of property who ALTER-DRAW&VENT-WATER(EA)
bu0d,tr Imprwn tpursua and who contracts for such p(ofects with a FEE SUMMARY
cgp(pacmr exempt
underuantrothe Conlrador�Llmnse Law. BACK FLAW PROTECT.DEVICE
I_J I am exempt under See B&p C for this reason
DRANSFIOOR ROOF,AREA,COND. SANITARY Y N Owner DataAFCmT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have ocertificateInsurance
c of consent to copy
thereof
ora RECEIPT N
certificate of Workers'Compensstlonlnsuranmaaartifled mpylhenmf(Ree. GAS,EA SYSTEl11 INC40U1LETS 3,(� PARK FEE Y N
Pol3800,lab CJ
Camai GAS-EA.SYSIM-OVER4(EA) RECER'T0
y BUILDING DIVISION FEES
Certified copy b hercbyth thecid. GREASE/INDUSTE,WASTE INTERCEPTOR PLANCHECKFEE
Certified-Py b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Dale Recti 4#
(Thlssection need not be completed If the permit b foron,hundred dollars
($100or1em3 , WATER HEATER W/VENT/RLFCTR ENERGY FEE Y N
Imrtlfy that In lhp edormence ofthownrk forwhlc this permit booed,
I shall not employ person any manryr m u t come b' to the WATER SYSIFld/TREATING
Worktn'eompe inns fCalRomfT.D — PAID
Q Z NUIIApplicant /a/ NEWRES(DENDALPLMB. 'Y]Fr. Date Rett'1 tk
Z 0 NOTICE TO AP :IL after ma king thio Ce a of Exemption,you
should bemmem d to the Workera•Compensa n provblom ofthe Labor TOTAL:
cc N Code,you most forthwith comply with such provisions or this pemdt shall be
>, deemed Invoked. BU '
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a mnstmctlon lending agency for the perform- ELECTRIC FEE
D Z arm of the work for which this permit is LLwed(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW bmIcoN(ylhal l have read thisapplloHonand datethat theaboveonformation
C rmo.I agree to comply with all city and countyordinances and gate law, PERMIT ISSUANCE FEES PAID:
>_ N relating to building construoion,and hereby authorize reprcepntativn of thio
1— Z city to enter upon the abovcmentloned property for Inspection purposes. ALTPRORADDTOMECH.
_ (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Recel 4N
agalnstllabllltle Judgmenb,consand expenseswh mayln anywayacdue AIRTEANDLINGUNTTITO1QOBECFM) - SUBTOTAL:
Ila! old y n cone nm of the ming o(� a perm
AR HANDLING UNIT(OVER 10,0BOCI'M) CONSTRUCTION TAX
Signature o rt/Comrador Date EXHAUSTHOOD fW/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appIlaut or future building occopent atom or handlehazardous HEATING UNIT OO 100,000 BTI0
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Dale Reeei tiff
Health and SafetyCode Stolon 25532(q? HEATING UNIT(OVER 100,0008770 TOTAL'
❑Yes MN.
Will theappllant or futum building ocrupant use equipment or devices VENDLATION FAN(SINGLE BESIDE ISSUANCE DATE
which emit hazardous air mnbminsnta as defined by the Bay Area Air
. Quality Management District? P
ict? BOILER-COMP OH OR 100,000 BTU)
q Yea Us
have read the hazarpus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �� tf QJI
the California Health&Safety Code,Sections y+25505,75533 and 75534. 1 1 1
understand that if the building does not mmotly have a tenant,that of is my NEW RESIDENTIAL MECH. SQ.Ff
nesponsiblllty to ndl/y the occupant of the requirements which moat be met
prior to bsua rice of a Certificate of Occup,ocy, 0 CUOP.IttO(fi
Owner or authorized agent Date
IDTAL: ISS
OFFICE COPY'