22407 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PLRMITNO.
BuRdo Ad msa8 U15 / 2 2 4 0 7
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M62407
p CITY OF CUPERTINO-BUILDING DIVISION (—t rq
"1 t
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APPLICATION IPERMIT l �
BUILDING ELECTRICAL•PLUMBINGMECHANICAL CATEGORY CONTROL N
biteci/Ggh a Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑ J
LICENSED CONTRACTOR'S DECLARATION APpLIANC6RE$IDEN7IAL
I hereby affirm that I am licensed under provkloa ofChapter 9(mmmenc JOB DESCRIPTION
Ingwith SLBion7000)of Dlvlslon3ofthe Sualneaand ProfeelonsCode,and my
license t In to d drect. PANELS _ esny
I.Ire . Lk.N
Date Contnci° n�
ARCHITECT'S DECIAR ION 201-1000 AMT'S
a0 ZCO I understand my plans shall be used a public remnla. OVER 1000 AMPS /L SQ.FT.FLOOR AREA S/SQ.FT.
d(0 Licensed Professional SIGNS ELECTRICAL �f ry E D ' A 1
lCu4 OWNERexNLDER DECLARATION 6_0 I�L T E Rv
1n a i SI'jTEMP.
ALCIRCUIT/M6C
f. Iherebyarnn. that Iamexemptfromthe Contractor'sLlrense law fort he
ZR—qqqq following rtason.(Sealon 7QT15,Business and Prolemlona Code:An tl or
PZI"'uf cvuntywhlNrequimsapemttommu dalter,impmvedemolth,ormpair MEfTR OR POLE INST.4 a nystmmm pdortolta kaence,also requlmtheapplicantfor such permit to file a sgned statement that he is licensed pursuant to the provikons of the R DEVICES ATP
3w� Contractors License Lew(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
SOS ston3 ofthe Iluelneea and ProreodoesCode)orthat he is exempt therefromand
yl_ the basis for the alleged exemption. Any violation of Section 70313 by any OUTLETSSWITCHES-FIXTURES
appBont for a permit subjects the applicant to a civil penalty of not room than
nvvndred dellae($500). NEWRESIDENTIALELECTR SQ Fr STORIES TYPECONSTRUCTION
�n 1,ate owner of the property,or my employe.with wages as their eck
worpensallon,willdo the work,andthe structure Is not intended or offered for
q Wale(See7044,Bukmix.cd Professions Code:The Contractor's License Law
$$ does not apply to an owner of property who Wilda or Improves theme,and OCC.GROUP RFS.UNITS
whodo.atchworkhimseefor[hreugh hiaownemploye.,provided thatuch
Improvement are not Intended oroffemd forale.If,however,the W ildingor TOTAL:
Improvement tsold withinoneyearofcomplk(ogtheowner-W llderwill have
tlt-truden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec 7044,Business and Profemlons Code:
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve therm.,and who comra , for such plct ojewith a
IN&or(-)licensed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under See B A P C for this reamn BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCIMOOL TAX Y N
Rkli hereby affirm that I have a.rtlnnte of consent to self-Insure,ora RFOER4 N
certlnote o(Worken'Compensatlonlnsuran.ora certified copy Memof($ec. GAS EA.SYSI'E7.11NC4 OU LEIS
3500.Lb d f1I I PARK FEF. RECE11TIs
ollcy N Y
Com an GAS-EA.SYSTEM-OVER 4IEA)
Y BUILDING DIVISION FEES
ertlfled copythereby furnished. GREASE/INDUSIRL WASTE INTER CEPTOR PLANCHECK PEE '
Certified ropy is filed with the city Inspection division.
CCRTIFICATE OF aJ . PFION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM En 200FT Date Reeel
ffhbsectlon need cot be completed the permit t forone hundred dollen PIX
(S1 l entifcss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
that[.the pen
m I.any
the work on1.as to
coag s bIcc toted, —
I Whale not employ any person In any rm e to berorrc eubfect to ted WATER SYSTEM/TREATING
Worken'Compenaadan laws of California.rnla. Date PAID
O Z NOTICE NEW RESIDENTIAL PLMB._SQ.FT. Date Re i tN
Z 0 Applicant
pplic fit APPLICANT.if,after making this ClnBlote of Faempuon,you
Hshould bmeme subject to the Workers'Compeaation provision fthe Labor TOTAL•.
CC N Code,you must forthwith comply with such provulons orlht permlt shall be
j deemed revoked. BUILDING FEE
LUCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them t a consuctlon lending agency for the perform. ELECTRIC FEE
0 ance of the work for which this permit t issued 6m 3097,Civ.Q TOTAL:
V _ lender's Name PLUMBING FEE
LLH Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL PGE .fe
O W 1entlfythatl havereacithtapplkationand state thatlheabove Information
trorrect.lagmelocomplywlthallcllyand rountyordleancesand ka/elawa PERMIT ISSUANCE 500 FEES PAID:
>- a relating to building ronstructler,and herebyauthoricerepresentativesoftht
1— N city to enter upon the abovementioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an If keep harmless the City of Cupertino Date Reeei tic
V against liabilities,Judgments,mks and expenses which may In any wayaccrue AIR HANDLING UNIT(TO ID,ODO CFM) SUBTOTAL:
ago d C1,;l ronaeque of the granting of this permit
' '� n I AIR HANDLING UNIT(OVER 10,M CFM) CONSTRUCTION TAX
S tmof Applicant/Contractor Date`7 EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applloot or future building occupant store or handle hazardous THEATING UNIT(TO 100,000 Bila Date Recei tR
material ate defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade Section 25532(a)I HEATING UNIT(OVER 10,000 STS!) �.
❑Y. ,]No
TOTAL;
Will the epplieousair
r W.I.building occupant use by tequiprocid he Bay Area devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which cook management
airrict? nta ate defined by the Bay Area Air
(juallfy Management Disldtl7 BOILER-COMP OFE'DR 100,IXM1 OTln P AID
K.
❑No q
4haveredthe havSfet rtode,Sercons 255ntundeand 2554. 1 of BOILER-COMP(OVER 10D,000 BTU) 151991
the California Health building
Code,onium25505,25533and25534. I Hp
undersand that If the notify the
not erequimhave a meat which
that It tray NEW RFSIDGN77AL MECH. SQFI'.
responsibility to nIXlfythe occupant of the requirement which moat be met i
prior to Issuance of a Certificate of Occupancy. Clly UUf�TC—UrtKjiI/V�sV�E��
Owner or aulhorired agent Data ISSUED
Vr" C /Vs•aN�w—�►
TOTAL:&40-0
OFFICE COPY