22169 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm en Identiflcatlon - PERMITNO.
Building Address:
Z /1 f'I aI 16 ar n
r C. 7 v/I—V.¢ /+-s /A �r- G G
rates ane:
A
n�/ C/FrQ/tJ' Sa'.45N$&A/ CITY OF CUPERTTN0.6UILDING DIVISION
d
c°^'r• ° • LI°•N APPLICATION / PERMIT J 7
GvAN ey�.S Cr3 BIALDINC-ELECnUCALPLUMBINCMECHAMCAL CATEGORY CONTROL
' Architect/Engimer. Lk No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcse PERMITISSUANCE LTJ CONTRACTOR'S DECLARATION
Iherebyatfirm that l am Leensed under provisions ofChapter9(commenc APPLIANCES-RESIDENTIAL JOB DFSC ON
IngwehSection force and di lona afthe Buslneseand ProfeWonsCode,and my
Licerlicena Is in fuR fors and ic.# PANELS
License Cbss Lk.N
Date Contractor —UP TO 20OAhVE
ARCHITECTS DECLARATION 201-1000 AMPS
XCO l understand my plamshallbe used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
od(/ Licensed Professional SIGNSELECTRICA (,L`'
a6
OWNER- ULLDER DECLARATION SPECIAL CIRCUIT/ LSC • Y tl
IherebyafRrtnthat lamexempt from the Contradoes License Law for the
following resson.(Section 7031.5,Business and Professions Code:Any city or
O TTMP.METEROR L I ST, t
PI, countywhlch requlresa permit to construct alter,Improve,demolish,orrepur
a ny.tmmmpriartoifs ance,aWmquirestheapphantforsuchper ito POWER DEVICES �J
file a signed statement that he b licensed pursuant to the provisions of the (/
qs Contractor's License Law(Chapter 9(mmrrcncing with Section 7000)of Div i- gyB,pgNC IDOL Q•E
O don3ofthe Buslnmesnd Pro/esslom Code)orthaheleemmpttherefromand -/ VALUATION
the basis forth.alleged exemption. Any ,violation of Section 7031.5 by any OU7LETSSWITCHES.F[MURE _ 00a,
�e
<� ci
appliantfora permit the applicant to a civil penalty of not more than
itt�undred dollars 5�.
I,as owner of the property, NEW RESIDENTIAL ELECTRSQFT. STORIES TYPECONSIRUCTION
�n p orl 4,a or my employees with wages r thele dole
.1.(Secompe7044,flown...l do the worksession rtrodurehelot Intended orcensoffered Law
q Bale(Sec.7014,Bminess and Professions;Code:The Contractor's License Law
$ dots not apply to an owner of property who Wilde or dmprevre thereon,and OCC.GROUP RES.UNITS
who doessuch work himself orthrwgh his own employees,provided that such
Impmvemenb are ns Intended orotfercd for ole.I(however,thebullding or TOTAL: .
Improvement bsold withlnoneyearofcompinlon,the owner-WRderwlll have
Ike hurden ofproving that he dldnM build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOOZONE APN
u I,as owner of the property,am exclusively contracting with licensed ppRMyf ISSUANCE
contractors to comtruct the project(Sm 7014,Business and Imfesdo.Code: �, D
The Contractors License Law does not apply to on owner of property,who
Wilde or Improves thereon, and who contracts for so& pkojects with a ALTER-DRAW&VENT-WATER LEA)
�gp�actor(s)hsnssd pursuant to the Contractors License Law. FEE SUMMARY
I_JI am exempt under Sec B k P C for this reason BACKFLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEBeT N
WORKMAN COMPENSATION DECLARATION FD(7URES PER TRAP SCHOOLTAX Y N
❑1 hereby affire,rkero that 1 have• Ensu ate of consent to op thereof
ora RECEIPT Y
3800,certifiabte ofWorken'Compensatlon Lurans oracertified copy thereof(Sec. CAS EA.SYSITM-ANCA OUTLETS Q'D PARKFEE Y_ N_
Polk Lab CJ
Policy Y CAS FA.SYSIAt-0VHR!(EA) RECEIPT N
Com any BUILDING DIYISIONFEES
Certified copy is hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b(Bed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID 1 _
COMPENSATION INSURANCE SEWF.RSANITARY-STORM EA 20aFT Date RC(%'1 ted ( 9/t4
Rhb section need not be completed tithe permit b(oro.hundred dollars F
($100)or I...) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill nor that fin employ
an person
e of any annex so as to become
permitls booed, D —
I shall not employ eny person In any manner so m m become wb)en to the WATER SYSTEM/TREATING
Worken'Compemalbn Ldwsol Callfomb.Dale - '� Pplp
O Z Applicant Date Remi tJf
Z O NOTICE TO APPLICANT:If,aaer making this Certificate of Exempllo",you NEW RESIDENTIAL PLMB. SQFI'.
should become subjedtothe Workers-Compensation provisions ofthe Labor TOTAL:
N Code,you at forthwith comply with such provide.orlhb permit shall W BUILDING IL > deemed revoked. '
d � CONSTRUCTION LENDING AGENCY . SEISMIC FEE leg
Ihfrcbyaorkfo whitat t iaermtrvciionssu ld(See.agfncyforthe perform ELECTRIC FEE R
n Z ansa!the work for which this permit is (See.3097,Civ.C.) TOT^L° �0 ✓
o2 Lander.Name PLUMBING FEE _ 0
LL F Landers Addeess QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Isdl(ythatlhavercadthb appliatlonand etatethalibeabove in(ornation
1 Iscorreds
.Iagreelocomplywllh all eltyand countyardloansand nate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby authorize representatives of this
F Z city to enter upon ted above-mentioned property for Wpectlon purposes. ALTER OR ADDTO MECH. Date Revel tl(
— (We)agree to save,indemnify an d keep harmless the City of Cupertino f2
agaWtBabiWke,pdgmenb,costsand expenses which nut In anyway accrue AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL
against said City in consequenceof the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appliant/Contractor Dale ExHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha nd Is hazardous HEATING UNIT(TO 100,000 RM pate
materia l as defined by the Cupertino Munldpa l Code,Chapter 9.1 2,and the _ Recei to
Ilealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 1 W,000 BTU) TOTAL: . 3
RYes MN.
ill the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hamnlous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) WWII L.•F
Yea
4 ouN
have.n c.dflnh. somd,maIsrequm,nents un JUN
der Chapterb.95of BOILER-COMP 100,000 BTU) J1j j,D�.•h
the CellfeHezlfh&Safdy CWd,Sectio.25505,25533and2S5M.1 UN
understand that lithe building does net currently have a tenant,that it b my NEW RRSIDENTIALMECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met Cj (�('iI[ji$'ItiQO
f prior to Issuance ofa Certificate of Occupancy.
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY