22138 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO. '
Building Addrea°: Q
avorl V'.Mo osis. Ci . Cv e�'ino 22138
wners com"e�:, e�5 0AVFU�iIUNhU1JM1T!7I:=A
Ci11rj�1-Ih r 9y9 CITY OFCUPERTINO-BUILDING DIVISION q I
. C9Rtam a-2p: L��S_�Q� LIn.N¢ APPLICATION I PERMIT t � q�
Architect/Engi..Jer. Llc No: BIALDINGdECTRICALPLUMBINGMEC}1AMCAL CATEGORY CO L
� BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERMITISSIJANCE ❑ 1:1 ❑
LIC NS EDCONTRACFOR' DECLARATION
T hereby off thatlam Bcensed underprov4lons olChapter9(common APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlih Section )of DlWtlon3ofthe Buslnevand ProfeWonsCode,and my
license Is In(u orae and a fe t. PANELS __
Date ContadarUP TO 200AMPS
ARCHITECTS DECLARATION 201-1000 AMPS 11
9OQC 1 mleaee my planssluit, used m public reCvNw OVERT AMPS f�t� .FI.FLOOR AREA $/S(2.Ff.
tj Licensed Professional SIGNSELECTRIC Uj 1, j_77.17f.
6 OWNER-BUILDER DECLARATION SIrECIAL CIRCUIT/ d a
�F, IherebyafOrmt
hat lam exemplfromthe Cont radar'6 Llcens law(m the
O following meann.(Section 70715,Business and Professions Code:Any city,or
F 1"'09 cauntywhichrequimsaper ttocenstrud,alter,lmprove,dem iB h,orrepair TFMIa.MEfFR OR POLE INSE.
anystrudure priorto Its issuance,also requirestheappllant forsuch Perna to POWER DEVICES
file a signed statement that he 4 licensed pursuant to the provisions of the
3w Coetradars License Law(Chapter 9(cemmencingwith Section 7000)ofDivi-
O�^ °ion 3 ofthe Busloses and Profeelon°Code)orthat he 4 exempttherefromancl SWIdhINGPOOLELECTRIC VALUATION
y�< the basisfor the alleged exemption. Any violation of Section 7071.5 by any OUTLET1 2 �
q� applicant fora permit subjedstheappllcant toe civil penalty of not morethan SSP✓ITCHESFT%'FURFS \ , i �Q�^W
a five hundred1,asoowner
of the pro NEW RESIDENTIAL ELECTR_ FT,
I deraf the property, SQ. STORIES TYPE CONSTRUCTION
�n ❑, p prty,orhe employers I. with rthelesols
compensation,wiltdothewormfmsdIonaCde:Th net Intended or
ctfor
sale(Sec.7074 Business and Professions Code:The Contradob Llanse Law
does not apply to an owner of property,who Wilds or improves thereon,and OCC.CROUP RES.UNITS
CC who does such work himself or through his own employees,provided that such
Improvements arc not Intended or offered for sale.If,however,the building or TOTAL:
Improvement Issold within oneyearofcompletion,the Owner-builderwill have
tden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
o- ryL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to ceentrud the project(Sec.7016,Business and Professions Code:
The Contredors License Law does not apply to an owner of property who ALTER-DRAW&VENf-WATER(FA)
builds or Improves thereon, and who contracts
for such ptojeds with a
cgp(fador(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
ec
Lf I am exempt under SB&P C for this reason
DRAINS FLOOR ROOF,AREA CONTI. SANITARY Y N OUTSIDEFEES
Owner Date Rl)rOPI'M
WORKMAN COMPENSATION DECLARATION FATURIES PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that 1 have a aminate of consent to pythsure,or RECEIPT#
3800,Laeo(Worken'Compensatloninsurana cox amlf4d spy lhereo!(Sm. GAS PA.SYSTEM-1 INC OUTLETS PARK FIX Y N
3800,lab CJ
Policy Y RECEICAS PA.SYSTEM-OVER 6(FA) DING Of
ny BUILDING DI VISION FEES
mined copy I.hereby te ty
Certified copy is(fled with
the city Inspection division. CREASEANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE
-
CERTIFICATE OF EXEMPTION FROM WORKERS• GREASE TRAP PAID 'y
COMPENSATION INSURANCE SEWER- STORM-STORM EA OFT. Date Recef t# _la
(Thlseectian need not be complded lithe permit ls(Drone hundred dollars
m Iormlyth WATER HEATER W/VENT/ELECTR ` ENERGYFEE Y N
(certify that in the peremanany rework for which this subjbOwed, —
I shag not employ any person In any nunner at ns to become eubjed to the WATER SY51PM/TREATING
Workcri Compensation laws of Gll(amia.Date PARD
O Z Applicant Date Remi t#
Z O NOTICETO APPLICANT:If,after nuking th4Cemifiesm or emption,you NEW RESIDENTIAL PLMB. SQ,FT.
sboald bcceme subject to the Worker'Compensat ton prov4lons of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be t
j deed revoked. I G E
W
meC CONSTRUCTION LENDING AGENCY SEISMIC FEE 2
I hereby afflrmthat there Is a censtmctlon lending agency for the perform- ELECTRIC FEE
Z ance of the workfor which this perMt is Issued(Sec.3097,Civ.C.) TOTAL:
V O Landers Name PLUMBING FEE
LL I— Lender'a Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iamifythatlhaversadth4appliatlonanddatethattheabovelnformatlon
IL [a cc red.l agree to comply with all city and county ordinances and state laws PERMIT L55UANCE FEES PAID:
>- Wrelating to building censtrudion,and hereby authorise representatives of this
H Z City to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Me)agree to save,indemnify an d keep harmless the City of Cu pen Ino Date Recel t#
V q.hatl4billtie°,/mdgments,coets dexpen whichmaylnanywayaccrue - AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalruisald Clty ie con" he grant got thio permit.
o 9 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Ignore of Applicant ntradr ° Dale� IX}IADST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA BDOUSM ER LS DISCLOSURE
Will the applicant orfutumbullding occupant stomorhaedle havrdou° HEATING UNIT CFO 100,00 BTU) Date Recei t#
material as dented by the Cupertino Municipal Code Cha)der9.12 and the - '
I I1ea�lth and Safety CodeSection75532(x)7 HEATING UNIT(OVER 100,00 BTU) TOTAL: I
Yrs q No
Ill theermt appacantor mrebulldingnants as occupant Bayequipment Area devise VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which eMahaement airrontamlvnts ore defined bythe Bay Area Air
Quality Management D❑4trid7 BOILER-COMP DFI'DR 100,000 BTU)
I Yes N No Ain luveread/he e.ith& pus CodeSuctemrcmen43533 and
6.95 of BOILER-COMP(OVER]lA,000BM �i4
the Gllfom4l7callh&Safety Code,Sections 75505,25537 and 25531. 1
understand that if the building does not cametly have a tenant that it is my NEW RESIDENTIAL MECH. SQ.FT I6
respoeaibnity, most to not By the occupa nt of the requirements which at be met ((JJ v �y
prior to Was one of a Gmi fiats of O=pa nry. t/
Owner or authorud agent Date ISSl1ED R� j� `���'� V Yr•J"C-Y,
TOTAL:
OFFICE COPY