22897 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification `2/NaN�� PERMIT NO.
Building Address: TT �r ` Vn
O 11"'� i•�o l,uc��-F Q V V V
22897
one: APPFicATT57PMMTM-ATT5A=
CITY OF CUPERTINO-BUILDING DIVISION Lb..2
contrador'a a m. APPLICATION / PERMIT
BUILDING-aECTRICAL-MUMBINGMECHANICAL CATEGORY CO a!1
Architect/Engineer. Lk.No: (�
lk
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
as—
Addroen PERVBTISSUANCE `issaxist, }I ��{J��1•
LICENSED CONTRACTOR'S DECLARATION I-TJ I—•�
Thereby af(Irmthatlam licensed under provlsiona of Chapter9(commenc- APPUANCES.RESIDENIAL JOB DFSCRBfDON
Inimsei l.ful]700m)of Dlvfent. f[he Businessand Profesdonscode,and my
license is Ins force and I PANLLS
License Cha
Fie.Dare Contamt
ractor
J_UP TO 2DO ANM
ARCHITECTS DECLARATION M14000A.MPS
q�q�uu a Cz I understand my plans shall be used a public records. OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FI'.
k z`j Licensed Profealanul SIGNS ELECTRICAL 13x")
<«<�.4 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
ao, Iherebyaffirmthatlamexemptfromthe Contractor'sLirenwnl f«the D
KZ.. following recon.(Section 7031.5,Buslnea and Professions Code:My city or TEMP.METER OR POLE INST. N
�QU rountywhic requlresapert ttomml d,alter,impmve,deonllsh,orrepair
mm anystrodum prior to its hsuance,alsorequlmtheappB®m for such permit to POWER DEVICES
K rile a signed statement that he 6licensed pursuant to the provisions of the
Contrador's License law Cls er9(commandn with Section 7000)of Divi- a ATION
( IR B av SWIMMING IDOL ELECTRIC
O slon3olthe Business and Profeabns Code)erthat helsexempt therefromand
5 rhe basls for the aBe ed exemption. Any violation of Section 7015 by any alt OUTLETSSWITCHESHXCURESUATE ��
<'a aPPI,..tfora permit subjects the appikant tvadvil penultydn«more than V O
n O five hundred della.($500). NEW RESIDENTIAL ELELTR
.$ SQ.FP. STORIES TYPE CONSTRUCTION
7 ❑I,as owner of the property,or my employees with wages as their sole
compensatlon,wllldotheouork and the structure strict Intended or offered for
Dsale(Sec.70f4,B°aineaaand Profeaiore Code:The Contractee-License Law
ES$ does not apply to an owner of property who builds of improves thereor,..it OCC.GROUP RFS.UNITS
who doessvch work himself or through his own employe.,provided that such
Improvements arc not intended oroffered for sale.If,however,the building or TOTAL:
Improvement bsoldwithin oneyearofc°mpldlogthe°wner-bufiderwlll have
[burden of proving that he did race build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIAODTONE AIN
u I,as owner of the property,am exclusively mntreding with licensedPERMIT ISSUANCE
contractors to construct the project(Sec.7644,Business ami Pro(ealons Code:
no Contractor's License law does not apply to an owner of property who
Wilds or imp m,d;thereon, and who contracts for such pCojects with a ALTER-DRAIN&VENT-WATER(EM
e'gRtf+dor(a)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am exempt under Son B &P C for this masonOUTSIDE 1`1 LS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Data RECEB'I N
WOR KMAN COMPENSATION DECLARATION pLXT(Igps PER TRM SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT N
«rtifieste of Worknn'Compereatlonlmurance«a«rtlfkd copythenrof(Sec. GAS F.A.SYSTEM-1 INCL OUTLETS PARK FEE Y N
3800,Lab C.)
RECEIPT N
Via
yS p GAFA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES
Cal�m rrang
"r IBM copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
Ceded copy Is filed with the city Inspection division. ^ 1
CERTIFICATEOFMEMPTION FROMWORKERS' GREASE.TRAP PAID �4 e�L$
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.IOOFD. Date ems tit
(Dissection need net be completed lithe permit is infers hundred dollars
($100)°flea.) WATER HEATER W/VENT/ELFJCTR 7 ENERGY FEE Y N_ Q�
I certifythat In the performance of the work for which 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 Iaws of California. Date Aa'1
0 Z Applicant NEW RESIDENTIAL PLMB. SQFD. Date ml
Z O NOTICETOAPPLICAM:If,after makingthls Certifl«teof Exemptim"you
should become subject to the Workers'Compereatlon pmvW ofthe Labor TOTAL:
N Code you=at forthwith comply with such provisions or this permit shall be BUILDING FEE 1
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Ihercbya(firmthatthem lsa constructionLendingW,Ci,orthe perform TO ELECTRIC FEE
M Z ance of the work for which this perMtblssved(Sec.3097,CIv.CJ
U O Lenders Name PLUMBING FEB $
LL I- I<ndcra Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r^
OW I«rtilythatl havereadthisappBnBona od statethattheabwainformation
C hcorn`d.Iagreeto comply wiehalldtyand muntyardlnanos and state laws PERMIT ISSUANCE �— FEES PAID:
r
mating to Wilding ronstmctlon,and hereby authorize represent selves of this
H Z city to enter upon the abovementioned property fo nspedlon purposes. ALTMORADDTOMECH. Date Receipt#
(We)agree to xve,Indemnl and kce ea the City of Cupertino AIR IIANDWNC UNIT RO 10,000 CFM)
U gairot BabiWin,pdgm can xawhkh may In anyway. zee SUBTOTAL:
against xid cit arca .ming olthls permit / CONSTRUCTION TAX
AIR IiANDUNG UNIT(OVER 10,000CFM)
ahs of Appli ontractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZAR DOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant store or handle haardous HEATING UNIT(TO 100,(O0 BTU) Date Recei tit
mnerial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Heal.and Safety c dlon 75532(a)7 HEATING UNIT(OVER IM,000 BTU) TOTAL:
❑ Yes No
Will the applkant or tNo building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which enut havrdous air contaminants as defined by the Bay Area Air p A p
Quality Managcmen d7 BOTLFR-COMP OHPOR 100,000 BTU)
❑ m Yes No
]have read the haus materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) _ ����
the Califernh Health&Safety Code,Sections 75505,75533 and 75534. I Nov
understandthatifthebulldingdoesnotcv ave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT 1'
r.poneibilityto no 0.5woto quirements which must W molt
prior to Issasrtftcfu�te Pancy. Cr(Y Ur l;UHtHImU
i
Owafforautho ' agent Date TOT ISSUEDBY
OFFICE COPY