22770 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Identification /�jy� �) PERMIT NO.
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Bu1�1Add
S yv � '/ 1 �`� yY 1 1 O
n amc: one: A
/n CITY OF CUPERTTNO-BUILDING DIVISION
cont nr' �}IF. : APPLICATION / PERMIT
A rchltect/Englver. A
• _ Y' BUILDINGELECTWL
CAPLUMBINGMECHAMCAL CATEGORY CONTROL N
Lk o:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERhRTISSUANCE ❑ ❑ ❑ TSI
LICENSED CONTRACTOR'S DECLARATION �(]
Humby
mthatlamllursed
---underlF�prov(dont of Chapter9(rommen
APPWANCESR-ESIDENTIAL
{r
JOB DESCRIPTION
Iecion7000)ofDl3ofthIBui
If...1b 1.0( died. 7afesslonsC°de,and my PANES
LIeNLirenecCb �
V
Date_Tel�Co';TECI
�Lder UP TO 2DOA�O
ARCHITECT DECLARATION OVER IO AMPS
reO ZpZO I understand my plan e1uN be uetd es puhllc remtds. OVER 1000 MPSTRIC rx SFT EA' N 5/SQ.FT.
0 Licensed Profcmlovl SIGNSELECLRICAL Car-q9 PUT 6 ° OtIamexNLDERDECLARATION SPFGIALCR(CUIT/M19C P U T
L., owing reffirmason.
Sutlamexempt fromthe Contractors Llcenx LawAny cit or
ZO$ following reason.(Section 7031.5,Business and Professbns Code:Any city or TEMP,M=OR POLE INST.
F vi to countywhichrequbaapermittommt d,alter,bnprovedemelbh,orrepair
S anystmcturc primblG lesuawc,alw requlrcsthe appllcantbnuch permit to POWER DEVICES
Ct O (Ile a signed matemnnt that he is Rrenaed pursuant to the pronsiom of the
Q6 3 u, Commcmr`s Lirenx Law(Chapter 9(mmmentlng with Section 7000)of Dh,-
� 5 mon 3ofthe Buslnessand Professl°v Code)orthat he b exempt therefromand SWUiMING POOL CTRIC VALUATION
the basis for the alleged exemption. Any violation of Sectbn 7011.5 by any 0[IlLETSSWI FIXTURES
applicant fora permit subjectetheappncant toa ctvll penaltym not more than
five hundred calbre($500). NEW RESID AL ELECTR SQ9r.
E]1, TYPECONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
eX rompensatlon,willdo the work and themmkure b not Intended or offered for
0 aale(Sec.761d,Rudnns and Professions Code:The Contractors License Law
ERR does wt apply to an owner of property who Wilds or improves thereon,and OCC.CNOUI' RES.UNITS
don such work himself orlhreugh his own employees,provided that such
Improvements are not Intended oroffered for male.If,however,thebullding or TOTAL:
improvement is sold within oneyrarofcomplmiom the owner-W ilderwlll have
the J2trden of perving that he did not build or improve for purpose of sale.), QTY. PLUMBING PERMIT FEE FLOOD TONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontranon to construct the project(Sec.70K Business and professionsCode:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improve.thereon, and who contracts;for such pto -
jects with a FEE SUMMARY
c9R(�adoK6)Licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under See B&P C for this reason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RFLIBPT p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER.TRAP SCHOOL TAX Y N
❑I heretry.(loan that I have o Inamentions,maof conecm m op theurc,ora RECEPT a
38M,cartiLa sofWoken'CompenaaHonlvuranaaarekfiled copythereo((Sec. GAS EA.SYSTF2N-1 INC.d OUTL PARK FEE Y N
Policy
N CJ oz-tlx('1$'J �7)q 11 .
Corn a W`•'r FJJ 1 _LJ DINRECG DIVISION
CAS FTA.SVSI'EM-0VER 4
Com assns I �' BUILDING DI VISION FEES
Corn
copy bTerebyth the city GREASE/INDUSIRLW INTERCEPTOR PLANCHECKFEE
rtificd copy b(fled with the tlty Inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER-SA Y-STORM EA 100F1' Date Recei -1#
IThb wdion need hat W completed i(thepermit la fororehundred dollare
($1I )orunify
lea..) WATERT TER W/VENT/ELMTR ENERGYFEE Y N
Icenote employ
the parsmanany he manner an as
pertnitbblued,
I ahrB not employ any perwn In any manner n v to become subject to the WA SYST[Af/TREATING
Workers Compensation Govt of GBmb.Date PAID
la
O Z Applicant RESIDENTIAL PLMB. SQ.F'f. Date RCceI t#
Z O NOTICE TO APPLICANT:If,aRer making this Certlfiute of Eaemption,you
should become wbkm to the Workers ns
Compeation provisions of the Labor TOTAL:
VT Cade,younustforthwithwmplywlthsuchprovlslovorthbpermltshallbe I
NG
W > deemed revoked. FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
0, 25
C 1hembya(nrmthat them b.avtmction Lending agency for the pekorne ELECTRIC FEE
M Z an.ofthe workforwhichthb permit Is bnued(Sea.3097,CIv.C.) TOTAL:
Q O' Lender's Name PLUMBING FEE
LLP= Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Iaklfythatl have read this applienionand katethatthc above Information
a bcmrrect.I agree tocomplywith all city and countyordlnamesandstam laws I PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and herebyauthortee repreaentativesof this
Zcitybenterupo above-mentioned property for Inspection purposes. ALTERORADDLOMECH.
U _ (We)a uve,Indemnify an d keep harmdeas the City of Cupertino Date Recei t#
agaWtll IB ,' dgmems,rmnand expense which may In a1w.yancrue AIR HANDLING UNIT GO 10,000 CPM) SUBTOTAL:
against Id n naequence fNe grant) gwtalm IL -
AIRHANDLINGUNIT(OVER IB,000CFM) CONSTRUCTION TAX
Signavreo(Appllcant/Contramor ate EXIIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building°ccupant store or handle hazardous F HEATING UNIT(TO 100,000 BTU) �, Date Recei t#
mzlerial'as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HrMthand Safety Cedrrc-S�ectfon25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: �
Fly. u No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RF-'ID) ISSjJAN _DATE
which emit hamealous air contaMvnts as defined by the flay Area Air gl,{A Rn c��]
Quality Management District? BOILERCOMP OHP OR 1(10,0(10 BTU)
4 Yea g.No
haveread teeth& out rCode,Se reons 25505,25S33
ernd 2SS3r6.95 of BOILER COMP(OVIR 100,000 BTU) R 11 .1�3I
the
erstan t Health building
Code, on cov25505,ve.ternd2S53N. 1
understand Ryonhat ftffy the occupant nm ct of e rentlyequir haves tenant,that It is NEW RESIDENTIAL MIiCH. SQ.Fi.
rpepr to issltyceofa Ctheesteo Occupe irenenitwhich rrwst be met MInArftp[N
icor to issuance ma Gklfkate of Occu an C�ty.(�
Owner or authorized agent Data s�.�f��,l/�y��,�
TOTAL: iSSUEDBV: �N/`/� $ /
OFFICE COPY