22726 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildijS Prom Idmtlfiodo PFR,11TNO.
Building Address: ,(�
VAQ-QO �" 6Ht00 PAPK SDI-IC_F 101& 8— I-nwE2 LC✓EL. 2272
neve aces. one: p p
CITY OF CUPERTINO-BUILDING DIVISION /
co nor'eName: uc.No: APPLICATION / PERMIT —(
/11/TZ ooj) wYl2K5 Sas BUILDING-ELECTRICALPLUMBING-MECH LAICAL CATEGORY CO
Architect/En neer.�ILIC No:
EC � el 0( b QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresa:SIN? VJIJUI;LEO AL)C .%u''1 AE✓Z PERMITISSUANCE � I �O D `g ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed u nder provisions of Cha pier 9(commmc APPLIANCES-RESIDENTIAL JOB DESCRRT[ON
ing with Section 7000)of Division 3 ofthe Business and ProfeaslonsCode,and my
licenulslnfaV deffen. (, PANELS / 1
LicenseClass Lic.N �Z6N)S
Date Contractor UP TO 20GANTS
ARCHITECPS DECLARATION 201-10DOA.ML'S
m0 z I understand my plans shallbe used as public record. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
{a CO
Licensed Professional SIGNS EIEC CA �L
�a OWNER-BUILDER DECLARATION SPECIAL CRZC T I (�� /` D I N
f., Z Ihercby affirm tlutlam exempt(romthe Contractorb Llrense Law fw the N A
Z9 fopowing reason.(5MIon 70!15,Business and Professions Code:Anyc or jPOWER:DEVI
ME1FR0 L
� �� countywhichrequiresapermittocomtmn,alter,lmprove,demolbh,ormpair [\ /]
q11 anystructure priortolts Issuance,aborequimstheappllcant for such permit to w�file a signed statement that he Is licensed pursuant to the provisions of the /Cntracto!Lice se aw Chap erg(comm nc gwithS ctlon 7000)o(Dvl- B NGPOOL 1 GD
O sfon3ofthe Bualnmand ProfmbmCode)orthat heiserempttherefvanairp _W&
,1
~ S2 the basis for the alleged exemption. Any violation of Section 76115 by any UTLETSSWITC MIRES . Q �{ �t1 v
6S Te
applicant fora permit subjects the applicant to a civil penalty of not more than �- V V
cR five hundred dollars(S500). NEWRESIDENTIALELECTR SQ.FT. STOW TYPE CONSTRUCTION
.. ❑I,as owner of the property,or my employees with wages as their sole
�7¢ compensatlon,will do the work and the structure Is not Wended or offered for
S ❑
.1c&c.7046,Business and Professions Code:The Contractoes License law
5$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROIlP RFS.UNITS
who does suchwork himself or through his own emplayees,provided that such
Improvements are not Intended oroQered forsale.If,hmveveg thebuilding or TOTAL: .�
Improvement lssold within oneyearofemopletion,the owner-bullderwlll have
tis,,parelenofprovingthat he did not build or Improve forpurposeof.k.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am eaclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profmions Code:
The Contractor's License Law does net apply to an owner of property who pLTQLDRAIN&VFM-WATER(EA)
Wilds or Improves thenen, and who contracts for such Ir Wouts with a FEE SUMMARY
co,p1B1(Funador(s)hrenwdpumuantwthe Contractor's Limns Law. BACKFLOW PROTECT.DEVICE
L_I I am exempt der Sec reason —
B k P C for this
OUTSIDE FEES
DRAM—FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT If
WORKMAN COMP FRVSATION DECLARATION MTURES��. 5Q IDOL TAX Y_ N
�1 hereby affirm that I have a certifia[e of consent to se141nwre,ora RECEIPT N
rertlfioteof Worker Compersatlon Insurance ora comfled ropythereof(Sec. GAS EA.SYSTEh,[_I WCAOUTLETS PARK FEE Y N
3800,Lab C.) —
Policy N RECET T N
Co any GAS EA.SYSTEld-OVER 4(EA) BUI LDING Di VI SION FEES
Mdified copy Is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTORPLANCHECICFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF IXEA
EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SpM.I.pRY-SIOftM EA.pDFI' Date Remi t#
(fhls seniors need na W completed if the permit Is forone hundred dollars
($100)or lm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performance ofthe work forwhich this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compensation laws of California.Date
-
0 ApplicantNEWRESIDENTIAL PLM B. Date Race) t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
H W should become subject to the Woikers Compensation provisions of the Labor TOTAL:CC
&
CW,you must forthwith comply wlthsuch provislovorthb pcmntahallbe BUILDING FEE .S
W —j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE r - O
CL E3 1 hereby affirmthat them is a construction lending agency for the perform, .00
D Z ante of the work for which this permit Is Issued(See 3097,Civ.C) TOTAL: FEE
ELECTRIC ECTRIC FEE
0 O Lender's Name
IL F Lenders Address QTY. MECHANICAL PERMIT E MECHANICAL FEE 1J
0 I redilythatl have read thbappliam
tionand statelhat theabove Woution
O W bcorrert.Iagrretocomplywithalldtyandcountyordinanarexnd state laws PERMIT ISSUANCE F' S/ 13o-9 (�
Nrelating tobullding construction,and hereby authorize representatives ofthis
H U) city to enter upon the above.mentioneA property for inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei t#
V agat bid ls,judgmma
enta.cost and expenses which y In anyway amus AIR HANDLING UNIT CFM)
WSUBTOTAL: 7
as aim ty equ o e antiWthlspertnit.
9 1391 AIR HANDWNGUMT(OVER IO,000CFM) CONSTRUCTION TAX
Sl'gnawmnf ontrador Date EXHADSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAM DISCLOSURE
Wllltheappliaaz
rat or building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
Health and Safety Codi ution 75532(x)7 HFATING UNIT(OVER 100,OOD BTU) TOTAL:
❑YesNa
Wlllthe applicant fu re building occupant use equipment or devices VFNIILATIOU FAN(SINGLE RESID) ISSUMA TE
which emit hazardous air mntaMmnts as defined by the Bay Arca Air
Quality Management DIs ct7 BOILER-COMP PHP OR 100,0(10 BTU)
4Yea ��C iNNo t0 C.W. Z 198
havercadthe haz4Nousmaterials requirements under Cha pler6.95of BOILER-COMP(OVER 100,000BTU)
the California Health ba Safety Code,Sections 25505,75533 and 25534.1
understand that if the building does not currently have a tenant,that It is my NEW RESI DENEEAL MECH. SQ.FT ckof C. :]
responsibI toneafythe pant ofth require rats which must be met 1t3B�"
prior to us ofa rtl ate fO nry.
O Q
Owner or Jame ISSUED BY:
TOTAL: 'V�
OFFICE COPY