22260 APPLICANT TO FILL KIN FORMATION WITHIN RED LINES— USE I BALL POINT PEN ONLY
Building Project Identification PEILWT NO.
Build0 AdAddress; -1 O qw l`/ 22.260
ID30g ./rtsUxAaa Tom ,
nese ante: one: p A
..I. e)ST 6 CITY OF CUPERTINO-BUILDING DIVISION
^n anmr.Nane: Lie.No: APPLICATION I PERMIT ID _ 3^
CATEGORY CONTR p
BUILDINGELECIRICALPLIIMBING-MEC}IpMCAl
Architect/Englneerl�- Llc.No:
QTY ELECTRIC PERMIT - FEE .BUILDING PERMIT INFO .„
Adores �
I'EFU9TISSUANCE •Z 0 p ISQ 1:1 1-1LICENSED CONTRACTOR'S DEC ION L)5,J
I herebyafurn that l amlicensed under provisions of Chapter9(commsic- APPLIANCES-RESIDENTIAL_ JOB DESCRIPTION
'ngwith Scnion 7D00)of Dlvision3ofthe Businessand Pmfesslons Code,and my
licence is m fuR formand effea. ' PANELS
License Clint Lica T`r, S I ��.//
Dale Contractor UPTOMOAMLIS
201-1000 AMPS .
Amshail CPSDECLARATION
m 2 I understand rtry glare shall be used v public records. OVER 1000 AMPS FI''E7'OO00
D I j/SQ.F.
�j Licensed Professional SIGNSELECTRICAL !6/.`l,L E NN
<w OWNER-BUILDER DECLARATION p�
I� i Ihaebyaffirmthatlame xemptfmmtheContmdor'sLimn.Lawforthe srECALCRCUT/MSC Y U T
2o an reason.(Section 7031.5,Business and Professions Crede:Any city or
O 2 F- TEMP.METLR OR POLE INST.
F�g.a eountywhieh requuesa pertNt to construct,alter, demolish,orrepair
.�
an
yatmcture prior to its issuance,also requlresthe applicant for such permit to POWER DEVICES �'
p, file a signed statement that he is licensed pursuant to the provisions of the
Contractors License SUv,(Chasser9(commencinwith Section 7D00)of Divi- VALUATION OS sion3mfthe Business and PrefessionsCode)orthaghe b exempt therefromand SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUILETSSWITCHES}7XITTRFS
applicant fora peritsubjectatheapplkanttoa civil pemu mor
at
mothan
m
CC five h ndred dollars($500). �,
,9. c NEW RESIDENTIAL ELECIR STORIES TYPE CONSTRUCTION
7¢ as owner of the property,or my employees with wages as their sok
nsatlon;will Bothe work and the structure isnot intended or offered for
g p sale(Sec.7010 Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RES.UNITS
who doessuchworkhimseif orthmugh hisown employees,provided that such oZr
Improvements are not intended oroffered forsale.It however,thebuilding or TOTAL:
Improvement bwld Mthinoneyearofcompletiogtheowner-builderwRlteve
theburdenofprovingthathedid not build or Improve for purpose ofsaleJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE -
contractors to construct the project($ee 70K Business and Professions Code:
The Contractors License law does race apply to an owner of property who pL�-DRAIN&VENT-WATER O+NN
Wilds or Improves thereon, and who contracts for such pWpaces with a FEE SUMMARY
actor(+)licensed punuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ -
Owner Date RECEIPI'N
WORKM COMPENSATION DELLA at to NTr^ p gES pEg.IRAP SCIIOOLTAX Y_ N_
❑I hem
by affirm that I have a certificate of consent to self-mwre,or a RECEIPT N
certificateafW.rkem Compensation Insurance ora certified copy thereof Gee. GAS EA.5YSTEM-1 INCA OUTLETS PARK EFF' Y N
3800,lab CJ RECEIPT It
Policy R Cu ffnyGAS EA.SYSTEM-OVER d(EA)
BUILDING DIVISION FRES
Certified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCQ'TOR PLANCHECK FEE
Certified copy u filed with the city inspection division.
CERTIFICATE OF FJ(EMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date Recei t#
(fhb section need not be completed if the permit efoe one hundred dollars
($lW)orlasa.) ENERGYFEE Y N
I melfy that In the performance ofthework forwMch this permit is Issued. I WATER 14FATM w/VENT/E.ECTR
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Iawmb
aofCalBo .Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t♦I
Z O NOTICE TO AI'PLICANT:If,after making t his Certificate of Exemption,you
should become subject to the Workeri Compematlon provisions of the Labor TOTAL:
CCN Code,you must forthwith comply with such provL•lons or this permit shall be B 1 DING
W > decried revoked. .
FEE 00
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Ihembyaffirm that there b a commuction lending agency for the perform TOTAL: ELECTRIC FEE - ll. Q
7 O ance of the workfor which this permit is Lswed(See 3097,Civ.C.)
V _ Lender's Name PLUMBING FEE
LL F Lender'a Addm QTY. MECHANICAL PERMIT FEE. MECHANICAL PEE
O W I'edifythatlhavereadthisapplimtlonandsttethattheabovetnformation
con.Iugrmto complywith act ntyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building cxnrsuuction,and hereby authorize represcro"ivesofthb
city to to enter upon the above,mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,pdgmenb,corsand expenses which may 1.any way accrue AIR HANDLING UNIT(170 10,ODO CFM)'' SUBTOTAL: —to
aSat idCity inconsequenscofthegra^tingofthis pe.mit
/ \ p✓S1 !// / AIR}lANDL3NG UNIT(OVER l0,W0CFM) CONSTRUCTION TAX
'Igmaxtuurre�olflf AZlpppp1RM//Contra,uctoa4.u� 'O of EXHAUST HOOD(W/DUCT) - CONSTRUCTIONTAXPAID:
-
HAZARDOUS MATERIALS DISCLOSURE.
Willthea licant or fuwmbuRdin ocm tstomarhandlchar ms HEATING UNIT(TO IOg000 BM
PP 6 Pa^ Date •Recei lk
material as defined by the Cupertino Municipal Cade,Chapter 9.1;and the
Health and Safety Cade Section 75532(a)7 HEATING UNIT(OVER t00,000BTU) TOTAL:
❑Yes MN.
Will the applicant orfumre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSI�ANCE-DATE
which emit havamous air cont Mmnts as defined by the Bay Arm Air - l'1EV
_ Quality Management District? BOILER-CAMP QHP OR 100,000 BTU)
4Yes ❑❑No ��� 'I 1 '{ Q1.
haee"adthehavNousmateriabrequlremntsunderChaper6.95ef BOB ER-COMP(OVER100,000 BTU) a {�V
the Glifcrnia Health&Safety Code,Sections 75505,25533 and 255M.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. _ SQ.FT. -
responsibility to notify the occupant of the requirements which must be met fL'6a d C 00
prior to issuance of a Certificate ofOavpancy. M�1
Owner r authorimd agent Data -TOTAL.: ISSUEDBY;, NIL= 1/k(J GSI
OFFICE COPY' '