22405 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMITNO.
Building Address: 3 f Q hoc oo� Qe , - 22405
r CITY OF CUPERTINO-BUILDING DIVISION 11 ���'a \
CBst@ n sName: E'{ TI(11.T _. n: O APPLICATION / PERMIT 6 b
Arcliitect/Enginee Lie. BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
.Na
QTY ELECTRICPERMIT - . FEE BUILDING PERMIT INFO
Address:I I n —
PERhBTISSUANCE ❑ ELECI
[:].
❑ LJ
LICENSED CONTRACTOR'S DECLARATION LSI
]hereby ion7Dthat l Division oftheBrproviders uf Chapter9de.and nc APPLIANCES-RESIDENTIAL JOB DESCRB'ITON
ing with Section 7000)of ddfmn3ofthegusinessand ProfessionsCode,and my
license is In fo d d(ect. PANELS
Lice Ch Lic.p
Date ContractorIndUP TO 200 ANTS
ARCHITECT' DECLAR ON 201-1000 AMPS
q.
MZ I understand my piava6 shbe used as public records. OVER 100O AMPS SQ.FT.FLOOR AREA $/SQ.FT.'+ OSIGNS ELECTRICAL
<Z(Uj Licensed Professional
G w OWNER-BUILDER DECLARATION
Ci FnSPFGIALCItCUIT/M1SC
F„ 7 ]hereby afllmnthat lam exempt frond the Contractor's License law for the
DOM". following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP METER OR POLE INST.
Fz county which requires a permit to covtruct,alter,Improve,demolish,orrepair
g Q� anystmMmpdwtolts Lswane,aL requlrestheappllontfwwchperMtto POWER DEVICES
0 file a signed statement that he is licensed pursuant to the provisions of the
qq Contractors License Law(Cha 9(commendn with Section 7000)of Divi- VALUATION
X05 sion3 of the Busmen and Pro(everbvCode)ortha8he is exempttherefromand SWIMMING POOL ELECTRIC
Q5 the basis for the alleged exemption. Any violation of Section 7MLS by any OIJ'ILETSSWITCI-IFSIq%NRES
OQ
applicant lora permit subjects the applicant to a civil penalty of not more than
$Cc fivehundreddollars($500). NEW RESIDENTIAL ELECTR
tf?G ❑T,as owner of the property,or my employees with wagon as their sole �'FT. STORIES TYPE CONS712UCTION
com
compensation will dothework,and the atcture Isnot Intended or offered for
D sate(Sec.7094,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon,and OCG GROUP RFS.UMTS
who does such work himselforthrough his own employees,provided that such
improvements arc not intended oroffered forsate.If,however,thebuilding or TOTAL:
improvement 6soldwithinoneyearofcomptetbgthe owner-W Bderwlll have -
theWrdenofprovingthathedldnotbulldorimprove for purpose ofsale.). QTY, PLUMBING PERMIT FEE �{.'hODp yONE APN
❑L as owner of the property,am exclusively contracting with licensed PERMHISSUANCE � - ! /
contsa=tors to construct the pmject(Sec.70K Business and Professions Code: �/
The Contractor's License law does not apply to an owner of property who ALTER
-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such ptajects with a FEE SUMMARY -
c tractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
❑I am exempt under Sec. B &P Gfor this reason
OUTSIDE ITS
DRAINSFLOOKRODP,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMP F]VSATION DECLARATION pp(T(JRpg PER TRAP SCHOOLTAX Y_ N
`�Q�I hereby affirm that I have o certificateInsurance
of consent to copy
therno ora RECEIPT N
3800 Lab of Worke[n�'Compenutionlvuranttwacertlficl copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTTHES PARK FEE Y N
..3800.Lab CJ !1 ,` ,a� RECEIPT M
»- - `7_11 Tc9D GAS-FA.SYSTEM-OVER a(EA) '
Cam assns �.� yl \ BUILDING DIVISION FEES
Cerified copy E hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM EA.2WFT. Date RCCCI t#
(THssectlon need not be completed if the permit b forone hundred dollars
($1M),uhad.) WATER HEATER W/VENT/ELEGTR ENERGY FEE Y N
I certify that In the performance of the work forwhlch this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compevation Laws of California. Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. �FT. Date Remi t#
Z O NOTICETO APPLICANT.If,after makingthu Certiicateof Exem)Hion,you
should become subj T to the Wmkeri Compensation pmvlsiov ofthe Labor TOTAL:
CC y Code,you must forthwith comply with such piovisiov or this permit shalt be BUILDING FEE
W > deemed revoked. _
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL rlbereby af(irmthat there V e mwtrvctlontendingage.4fortheperformELECTRICFEE
D Z arcs,of the work for which this permit ii Issued(Sec.3097,Civ.C.) `TOTAL'
02 tender.Name -- FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT" FEE MECHANICAL FEE
O W lmdifythatlhavereadthisapplicatWnandatatethattheaboveinfomutlon
C
beemed. comply wlthail dtyand countyordinances and state taws Puth1ITISSU :
ANCE 5 — FEES PAID
>- relating to building construction,and hereby authorize representatwesafthh
Zcity to enter upon the above-mentioned property for Wpeetion purposes. ALTER OR ADD'fO MECH. DCTC RCCCIPI#
(We)agree to save,indemnify and keep harmless the City of Cupertino
(')
against liabilities,judgments,costs and expenses which may to anyway accrue AIRRANDLINGUMT(TOI0,000CFM) SUBTOTAL:
BEA iin
.gat t a Clty in consequence of granting oft la Fell!,l
AIRHANDUNC[ATI(OVERt0,000CFM) CONSTRUCTION TAX
sqwrCS n to eof Applicant/Contract E%HAUSTfI00D(W/DIKT)
ONSTRUCTION TAX PAID:
HAZARDOUSMATERIAL 'CLOSURE
ilttheapptiant or future building oecopan store or handl a ndous HEATING UNIT(TO 100,WO BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
ltealthand Szfdy Code Sectlon25532(a)? HEATING UNIT(OVER 100,000 BTU) - TOTA . ` e
❑Yes n No ..
Will the applicant or Wture building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE.
hich emit hamixim s air contaminants as defined by the Bay Area Air
lity Management District? BOILER-COMP QHP OR 100,000 BTU)
Y s FF��No
shave read ihehaza9Ou.matedxlsrequimm ntsundcr Chapter6.95of BOILERGOMP(OVER 100,000 BTU) PAID 1. '
the Glilomia)iealth&Safety Code,Sections 25505,75533 and 25539.) f W
'understand that if the building does not currently have.tenant,that It is my NEWRESIDENTTALMECIL SOFT.
responsibility to notify the occupant of the requirements which must be met 1 1991
prior to issuance of a Certificate of Occupancy. W�ov.sy+
Owner or authorized agent Date TOTAL: ISSUED T'(`a"IYP4
OFFICE COPY