22722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
��y '( •� 22722 Building Address:
PrRMITNOO.. 1'/'J 7 I'/') /n
weerr / o A A
CITY OF CUPERTINO-BUILDING DIVISION \^
co^(�aao'eNa APPLICATION / PERMIT
I1� BUILDINGELECTRICALPLUMBING-MLCHAMCAL CATEGORY CONTROL It
Architm/Engines. Lk.No:
' QTY ELECTRICPERMIT FEE . BUILDING PERMITINFO',
PEih4TISSUANCEEl 1:1 E ria
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ectionrmthat laiv Ucmwdunder Busi essa ofCssions odcanenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Info 7000)of Divi91on3o(the Busineuan (eaUonsCade,and my LI y y
ILmnse b in fu cad sic.# �J-,� PANELS `tet. C'�/n�•'
License Class a Conte -oN
Date Contractor. III!IQ 2M AMPS
-
ARCHITECTSDECLARATION 201-10DOAMPS
rc0 2 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/5Q.FT.
O
Licensed Professional SIGNS ELECTRICAL
¢N OWNER-BUILDER DECLARATION SPECiALCIRCUIT/M15C s
F ,7j Iheeby affirm that am exempt intention Contractor's License law for the II�� pp p�
29 following reason.(Snct1on70315,Businessand Profession Code:Any city or Q- pa B SLC
FLI"'c countywhich requires a permit reconstruct,alter,Improve,demolish,orrepair 741E METER OR POLE INST.
anystmcture priorto its issuance,also requires theappBrant fun-such permit to
q ]OWER DEVICES 12
E d fie a signed statement that hat licensed pursuant the provisions;of the
Contractor's License Law(Cha er 9(commencingwith Season here)0)of Divl-
30�' sion3 ofthe Businessand Professsslom Code)mthat hebexem lherelromand SWIMMING TOO ECTRIC VALUATION
5 the basis for the alleged exemption. Any violation of Section 70315 by any o m E ESFD ruREs �7} Uh t Urch 1 IIVU
« applicant for a permit subjects the applicant to a civil penalty of not more than /
five hundred dollars(SM. NEW R ECTR
SQFr. STORIES TYPECONSTRUCTION
t,¢ compensation
❑I,as owner of the property,or my employees with wages thele sole
pensati;i,will Business
the work and the 9imctureh not intended or coffered for
$�❑ sale(Sec.70dE,BusNess and I'Messlom Code:The Contractor's License Law
does not a pply to an owner of property who Wilds or improves l herron,and OCC.GROUP RES.UNITS
who doessuchworkhonseiforrhreugh hisawnemployt provided that such
improvements are not Intended orofferedforsale.If,however,the building or .TOTAL:
improvementissold withinoneyearofcoenplellontheowner-W ilderwill have
Ih,OEurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the Property,am exclusively mntraafng with Ilm PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Prefe came,Code:
The Contractor's License Law does o
not apply to an wner of property who • ALTER-DRAIN&VENT-WATER(EA)
Wild.or improves.therean, and who contracts fee such pwjects with a FEE SUMMARY
tj"+et en 0)Banned pursuant to the Contractor's Lim..Law. BACK FLOW PROTECT.DEVICE
I__I I am exempt under SB k P C for this reason
-OUTSIDE FEES
P SANITARY Y N
Owner - Date DRAINS-FLOOR ROOF,AREA,GOND. RECD,p
WORKMAN COMPENSATION DECLARATION Fp((URES,PER TEMP SCHOOLTAX Y N_
I hereby a(flrn that I have a certificate of consent to eel!-insure,ora RECEIPT p
ILcate,of Workers CmmperesaBonlosuratoe ora certified copythereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS NARK FEE y N
38DO,Lab C.) •"
asaV RECEIPT p
PoBry p GAS EA.SYSTEM-0VFR 6(EA)
- Com any BUILDING DIVISION FF.[B
PCertified p Ls hereby cola& CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city Irepection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA pDFI. Date Receipt#
(The section need net W completes tithe permit isfor one hundred dollars
($IW)orles..) WATER HEATER w/VENT/ELECIR ENERGY FEE Y N
I certify that In the performance of the work forwhich this permit is blued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensatlonlaws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PCMB. SQFI'. Date Recei t#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CC j Code,you most forthwith comply with such prov6ions orthla permit shall be BUILDING FEE
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE
t1 O Ihereby aorkfor w there bacomtmction lendingsumi(See. ,Cie.C.) perform TOTAL: ELECTRIC FEE 1
L) 0 Leude,toom the work for which this permit btsued(Sec.309],Cie.C.)
() 1<neee'shamePLUMBING FEE _
LL I— LendersAddess QTY. MECHANICAL PERMIT' . E MECHANICAL FEE
OW 1cenlfythat l have read thisappliation and statethatthe above information
IL iscorrect.Icgree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authotlu representatives of this
(A city to enterupon the above-mentionM property for Inspection purposes. ALTERORADDTOMECH.
2 (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V a alrutllabihties,lydgmnnts, xs expenwswhichenayinanyway..e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gal aid City In con Ith gra t of this permit.
AIRHANouNcuNrr(ovFxlo,000cFit) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Sigvturco ApplHA ea Date EXHAUST HOOD(W/DUCT)
HAZrfut AT RLALSoccupant
DISCLOSURE
Willtern the applicantbythe futurebuildingM oaipal Cods,Chater9a hazardous fiEATLNCUMT(TOlW,000 BTU) Date Ree21
material a9 defined ue the Cupertino Municipal Code,Chapter 9.12 and the - -
Hallhand5afetyCode on 25532(.)7 HEATING UNIT(OVER IW,OW BTU) IOTA
F 1 sec No
TNi111heappBrantarfu rebuildogoupant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit M1vumdous air contaminants as defined by the Bay Area Air ,
Quality Management 1 i BOILER-COMP QHP OR 100,IXp BTU) IIIn�
Yea No Jk'Ipl
I have read the M1azasene materials requirements under Chapter 6.95 of BDILER-COMP(OVER 100,000 BTU) co 2199
the California Health&Safety Code,Sections 25505,25533 and 2S53d. 1 r 6
und.l.n thaofthebulldingd.n m.rrentlyhaveatenant,thatittsmy NUNRESIDENTIALMECH. SQ.rr L/Y L
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Otto parry. //YL/
Owner or authorized agent Date r"l ro"7- s ISSUED BY:
OFFICE COPY f- f