22511 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Budding Address: ��� 2 2 511
ID123 �a �,Ot..� tZAD,
wners one. APPLICA HON SUB.qnTA-=
L: CITY OF CUPERTINO-BUILDINGDIVISIONQ—'C(
k
APPLICATION /PERMIT 77'�
L �t BUILDINC-ELFC7RICALPLUMBING-MECHAMCAL CATEGORY CONTROL
Arehited/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ 1:1 1:1R
LICENSED CONTRAROR'B DECLARATION 1751
hereby n70irm that)am licensed under Busineprovisions
andP ffesMmsr de,and(commec- APPIlANCISRESIDENTIAl JOB DFSCRIrT10N
in erse I Senion force of d afslon3o(the Buslnessandl'rofnsiom Code,and my o
limn.Is In full force and effect. PANELS l ,
LIcen.Class—
Date ContCort ractor —UP TO 200AII25
ARCHITECTS DECLARATION OVER IOAMI'S
q+otoz [understand my pians e1uBWused as publicrecoils. OVER 1000 AMPS `U.FLf AREA $/SQ.Fr.
o D N
Ft��j Licensed Professional SIGNS ELECTRICAL
<<In C Lt OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC I 1
t, Ihereby affirm that am exempt from the Gentranorb License Law for the V
Z
'� following reawn.(Sed)on 70115,Business and Professions Code:Any city or �(p METER OR POLE INST.
TER
0 � county which requlma permit tomrut ut,alter,lerpmve,demolish,orrepair 19/W
Q //_
anystmdumpdortoitslssuance,ahorequimstheappliantforsuchpermitto POWER DEVICES CrJ c/
6O 0.O file a signed statement that he In licensed pursuant to the provisions of the
Q3u,GContractor'•License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O .sion3 of the Business and Prefessi.Code)mthat he b exempt therefromami
Ser g the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWIT'CHESFIXTTJRES
applicant for a permit subjena the applicant to a civil penalty of not more than
five hundred dolhn(A500). NEW RESIDENTIAL ELECTR FT.
I,as owner of the property, `� STORIES TYPE CONSTRUCTION
p perry,or my employees with wages r thele sole
7�
compensation,(Sec.7KBusinessnd work,Pr andthe s Code;The
Contor ended orcamoffered Lsw
�O
sale(Sec.7066,Pusinesaand Professions Code:The Contractor's License Law
({$$ does not apply to an owner aproperty who Wilds mrimprove•thereon,and OCC.GROUP RES.UNITS
C. whodonsuch work himcEorthrwgh hisown employees,provided that such
Improvementsare not Intended oroffered for sale.If,however thebuilding er TOTAL:
improvement iswld within oneyearofcompleiom the owner-W Ilderw111 have
tt1jZurden of proving that he did net WOa or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD WIVE APN
u I,as most of the property,am exclusively contracting with limner PERMIT ISSUANCE
contractors to mustrun the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT WATER(EM buBcis or Improves thereon,and who contracts for such p,jects with a
Nwebor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this re
OUTSIDE FEES
aeon DRAINS FLOOR ROOF,AREA,CON). SANITARY Y_ N_
• Owner Date RECEII'Ta
WotAN COMP TION DECLARATION p� APER TRAP SCHOOL TAX Y_ N_
❑I hereby affirmrm, a cemthat I have•mrciRate of consent to.if-Insure,ora RECEIPT 9
certificate ofWorkeri Compensalonlnsurance ora arclfied copythemed(Sec. GAS EA.SYSTEM-1 INC OUTLETS PARK FEE Y N
350),lab C.) RECEIPT
jr
Policy M GAS EA.SYSTEM-OVER d(EA)
Co RINGVISION FEES
;Allied copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy in filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEYJER-SANITARY-STORM EA MFT. Date Recei t#
(Thlsse tion ne d nm be compldd lithe permit b foronc hundred dollan
(SIW)Orlca.) WATER HEATER W/VENT/ELFLTR ENERGY FEE Y_ N_
I certify that In the performance of the week for which this permit la blued,
I shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING PAID
Workers'Compensatlonlaw•of California. Date
-
0 Applicant Date Re i t#
Z rp NEW RESIDENTIAL PLMB. SQ.FT.
Z 0 YOTICE TO API'l.ICANT:IC after maWng thio Ccrciflmte o(Exemptbn,you
should become subject to the Workers Compensation provisionsof the Labor TOTAL:
A Code,you=at forthwith comply with such provlslons or this permit shall b, BUILDING
deemed revoked. '
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby affirm that there ba mrstmction lendingagency forthe perform TOTAL: ELECTRIC FEE
0Z arm of the work for which this permit is lssued(Sec.3097,Civ.C.) PLUMBING FEE
L) O fender.Name
LLH Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedifythatl have read thbH
appliczonand statethat theabove Information
O W iscorrect.I agreeto complywith all cityand county ordinances and state laws I PERMIT ISSUANCE eQ2 FEES PAID:
). IL relating to building construction,and hereby authorize representatives ofthls
F U) city to enter upon the abovo-menllond property for inspection purposes. ALTER OR ADD TO MUCH. a�
(We)agree to save,indemnify an d keep harmless the City Of Cupertino Date Receipt#
V against llaMIhk ' dgments,costa andexpenseswhich may In any way accrue ATR HANDLING UNIT(170 BLOW CFM) SUBTOTAL:
agairot said �yl comequu I h grantingoftMspermit��'nI CONSTRUCTION TAX
-Ty� L 'L"'//t//�/Ir �) l AIAIfANDLINGI1NTf(OVERIO,IXpCFM)
Sjgnatum of Applicant/Conte Date EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDO ATERIALS DISCLOSURE
Will theappllantorfutumbufidingeccvpant store or handle hazardous HFATINGUMT(TO 100,0008711) Date Refei l#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
kiealth and Safety Cede Section 25532(1)? HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Y. M No
Willtheappllcam or future building occupant use equipment ordevices VEMILATIONFAN(STNGLERESID) I s� ISSUANCE DATE
which emit haradous air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP DI IP OR 100,IX1)BTU)
Yes No
have read the hazy mus materials requ irements u nder Chapter 6.95 of BOILER-COMP(OVER 10(1,000 BTU)
the California Health k Safety Code,Stolons 75505,25533 and 25534. I �ry*
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F(
responsibility to notify the omupant of the roquirements which must be met J /
prior to Issuance of a Certificate of Occupa nry. t'E vsyrT h_� `�.{S 0 �x•sla
Owner or awhomad agent Date W ISSUED Rd•lF9f
TOTAL:
OFFICE COPY