22578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Addrett: 22578
wnero aces:, 1 one. p q A
,PS /"1 a h �ti' CITY OF CUPERTINO-BUILDING DIVISION
onmetor's Name: uc.Nr: APPLICATION it PERMIT
6u m f7 Yl �I U a`ia ss 3 BUILDINGELECTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL N
Archimt/Engineer. Lic.No:
/ ^ QTY ELECTRICPERMIT FEE _ BUILDING PERMIT INFO
. .gaama: I'7��l VCY- i/L Q. 5•�• !A. PFRMITISSUANCE ❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
thereby alficon that lam licensed anderprovulons o(Chap[er9(crimmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTIO
iI...I I.
forge fd efeon3oftheBusinessand ProtesslonsCode,and my _ I �s-
liconse le In(ul lore rad effect yam-!, PANELS �(� 1�
License Class `s tic.« 619.;4 5 1'
Date i- IL-41 Contmeto�irczA e"n cA _
ARCHITECT'S DECLARATION X11-10DOAMPS
QRZ I understand my plans shag be used as public records. - OVER1000"I'S - SQ.Fr.FLOG EA ' S/SS .Fr.
F�Z Licensed Professional SIGNS ELECTRICAL' pA1� L E.� _
<c. OWNER-BUILDER DECLARATION M TSE
p y 'v 1
L., Z Ihercby a(0 e
affirm that xemptfromlhe Contractor's license law for the SPECIAL GR2G(RT/M15C
O'y u9 following reason.(Section 70315,Business and Professions Code:Any city or Tp.Ip METER OR POLE INST.
c
�p ntywhichrequlreeapermittommtmd,alter,impmve,demolbh,ormpair �1 3
anystruentre priorto its hatuance,also requires theappBcent for such permit to pOYVFRD��g o
file a signed statement that he is licensed pursuant to the provisions o! the
40,I— Contractor.License Law(Chapter 9(comnnncing with Section 7000)of Owl- SWNSMING R70L ELECTRIC
05 slon3olthe Buelnessand ProfessionsCode)orthat he u exempt therefromand VALUATION
`u�¢5. the bash for the alleged exemption. Any Violation of Section 7m1.5 by any OUTLETSSWITCHESFIXTIRiES
v
applicant fora permit subjects theapplicant to a civil penalty of no room than
a o ' five hundred dollars(W.
1 as owner of the property, - NEW RESIDENTIAL ELECTR SQFT, STORIES TYPE CONSTRUCTION
�ZZQ compensation,will do thwork, the my
is nor Intended or offered for
5_ p sale(Sec.7044,Business and Professions Code:The Communes Live.Law '
does not apply to an owner of property who Wilds or improves thereon,and
n'$^ whodoessuch work himseifrnthrough hisown employees,provided thalsuch OCC.GROUP l RFS.LINKS
Improvements are not intended reoffered forsale.If,however,thebuliding or TOTAL:
Improvement is sold within oneyearofcomplrtioM tM owner-bullderwlll have
rite rden of proving that he did not build or Improve for purpose of sale.). QTY, - PLUMBING PERMIT FEE FLOODZONE APN
1,as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
sm
contractors to construct the project(Sec.7044.Business and Professions Code:
The Contracture License Law does not apply to an owner of property who
Wilds or Improves thereon„and who contracts for such ptojeM with a ALTER-DRAW k VENT-WATER BTA) _
cdarts)licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE ' FEE SUMMARY
Ifam exempt under Sec. B k P C for this reasonOUTSIDE FEES
S FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner 1 Dae DRAINRECEIPT N
WOR KAN COMPENSATION DECLARATION FIXTURES. TRAP SCHOOL TAX Y N
❑1 hereby af(Irm That 1 have a certifiote of consent to self-Insure,ora RECQ[rl'N
certiflate of WorkerCompensation Insurance or a certifiedpy cothereof(Sec. GAS EA.SYSTEM-1 WC.40fIILEfS PARK FEE Y_ N_
3800,lab CJ
RECEIPT N
Policy N' GAS FA.SYSTQd-0VFR4(FA) -
Cum any _e3Cr CSR- R'T` S BUILDING DIVISION FEES
[ACcAlfied copy b bercbytumecity GREASE/WDUSLRL WASTE INTERCEPTOR PLANCHECK FEE
' hd
h.ICertilled<opyb(iled with the ttyinspetion divisors.
'''WW CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM E.A.XIOFI. Date Recei [#
(Thlssetma
lon need t be completed if the permit la forone hundred dollars
($100)orless.) WATER]iEATFRW/VENT/F1.ECTR ENERGY FEE .,Y_ N
I mriRythat In the performance of thework for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTIM/TREATING
Wrrkcrs'Crmpensation Lxwsof California. Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQFL '
Date Recei t#
Z 0 NOTICE co e,APPLICANT:eWorrers'Co Fe unionCertifpro is Exemption,you
F W Code,shoulyou
must ubFwith co plywit'such pruatbnprovhions of rmit slab be s .w0_ -.a 00 TOTAL:
� �
Code, forthwith comply with such provisions orthla permit shall be "'�Rt ss�G ` `-V BUILDING FEE
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Ihercby affirm thatI.,w which
this
aconatmcissued(Sec.ion 30enq f.C.) per(oran ELECTRIC FEE
7 Z ancoofthe work/or whkh this permit is Issued(Sec.3097,Civ.C.) TOTAL: I 1
(.) 2
O Lenses Name - - PLUMBING FEE
I- lenaersgaareas - QTY. MECHANICAL PERMIT FEE
OLUrem.Izgerhavemaathlaappumtmndcountyonlinancesamframatmn MECHANICAL FEE
Q. urorrct.Iagaee to complywith aBdtyand county ordlnanmand statelaws IrptMR ISSUANCE FEES PAID:
} W relatingto Wildingcnstruction,and herebyauthoriu representatives ofthis -
(.- Z cityto enterupon the above-mentioned property for inspection purposes. ALTER OR ADDTO MFCH.rtino Date Receipt#
demnify an d keep
ity of
V
against liabilities,pcigmee to save, ems matsand expenses which may ess the Cln any ayaceme AIRFLANDLINGINIT(TO10,030CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIRHANDLINGINIT(OVERl0,000C11s4) CONSTRUCTION TAX
I” CONSTRUCTION TAX PAID:
arca Appicant/Contractor Date EXHAUSr HOOD(W/DI1CT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 10EWO BN) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the r
I trahh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Yesr]No I - -
WllltheappliwNI
ntrr futurebuilding occupant use equipment or devices VEILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined bythe Bay Area Air Pad t/Kx
Quality Marugemem DMrlct7, BOILER-COMP OTB'OR 100.000 BTU)
Yes
I I—I Nr n
have read the hazes ase materials rcquirementsunder Chapter 6.95 of BOILER-COMP(OVER Se t 100,000 BTU) UG12
the California Health h Safety Code, ions Z 50S,25533 and 25534. I
understand that if the Wilding does not currently have a tenant,that It is my NEWRESIDENTTALMECA. SQ.FT. LLtl��
- responsibility to notify the occupant of the requirements which most be met ail.
W
prior to issuance of a Certificate of Occupancy. 1Y-{Wy��� •,
Owner or authorized agent Date TOTAL: ISSUEDBY:
OFFICE COPY