22433 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification 7 PERMIT NO.
Building Address: 22433
'�_Z2d471 C0G Ca.I o D — .vJ G
meas ams: I one: p q A
v r = tPys CITY OF CUPER'I'INO-BUILDING DIVISION
contractor's Name: Lie.No: APPLICATION / PERMIT -7
�� BUILDING-ELECnUCALPLUMBINGMECHANICAL CATEGORY - CONTROL N
Amhlted/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO .
Address: PERMITISSIJANCE �CT71� ❑
LICENSED CONTRACTOR'S DECLARATION IK'
I hereby affirm that l am licensed under It olonsof Chapter9(commmc APPOANCESRESIDENTIAL JOBD
Ing with Section=)of DiWslon3ofthe Business and PenfssloesCods,and my
license lslnfull force and effect. PANELS �L�' IF
��a•
License Class LICs �o- .x T
Date Contactor TN-+
ARCHITECPS DECLARATION 301-1000 AMPS
niZ Iunderstand my plans shall be used as public remade. OVERIODOAMPS E SQ.FT.FLOOR AREA $/SQ.FT.
O in
i✓,V Licensed Professional SIGNS ELECTRICAL I "{ -, I
9N
<cce. OWNER-BUILDER DECLARATION 1 J IU
ffid v, SPECIAL CIItCUIT/MIST IL
i.., Z owing rason.(hatlam31-5,B fromthe Contractor's License Law fort he i
Z O following reason.(Section 78715,Business and Profembm Code:My city or TEMP METER OR POLE INST. u
KZ � countywhich rnrylma permit to construct,alter,improve,demolbh,or repair
K .-r anystmcture pdorto its Wounce,also requlrestheappliant for such permit to POWER DEVICES 7.
file a signed statement that he is licensed pursuant to the provisions of the
�S3�N Contractor's License Law Klupter9(commencing with Section 7000)of Divi. SWENMING POOL ELECTRIC VALUATION
sion3ofthe Businemand Profeaslurse Code)orthat heb exempttherefromand �ax�
the basis for the alleged exemption. Any violation of Section 7871.5 by any OUILETSSWITCFffSFIXTITRES I QQ
applicant fees permit subjectstheapplkm
auttoa civil peltyofnmt morethan T
live hundred dollars(¢500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRICTION
�I,as owner of the property,or my employees with wages as their sok
compensation,will do the work and the structure b not Intended or offered for
5 O sale(Sec.7044,'Busbies, and Profs lo�Code:The Cont.does Llmrue Law
does not apply to an owner of property who builds or Improves thereon and OCG GROUP RFS.UNITS
who does such work himselforthrough his own employees,provided that such
improvements are not intended proffered forsale.If,however,thewilding or TOTAL:
improvement u sold within one yearofcompietion,the owner-budderwlll have
he Jyrden of proving that w did not wild or Improve for purpose of sale.), QTY. PLUMBING PERMIT FEE FLOOD zoNrE APN
c I,as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
ntractors to construct the project(Sec.7044,Business and Prefesslom Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p4ojem with a ALTER-DRAIN&VENT-WATER(EA)
. collt.[ador(s)Bcensed pursuant to the Contnctor'e Lkense Law. - FEE SUMMARY
LJ attests)
exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION PEKTURE5PER.1.�I, f'') SCHOOLTAX Y_ N
❑I hereby affirm that I have a certiflate of consent to eel(-Insure ora .a-t RECD.N
certificate ofWorkers'Compensation Insurance or a certified cupytherrof(Sec. GAS FA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800,his C.) - _ RTC=p
Policy s CF�ICAS EA.SYSTF]d-OVER 4 01A)
Com any BUILDING DIVISION FOES
Certified copy is hereby with
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified copy u filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT.. Date Recei tit
(This section need not be completed if the permit Is for one hundred dollars
($100)or less. WATERHEATFRW/VENT/ELECTR ENERGY FEE. Y_ N_
I certify that In the performance of the work forwhich this permit is Issund,
I shall not employ an7 person In any manner so as to become subject to the WATER SYSTEM/TREATING
orkers'Com fCpbfomla.Date PAID
pliant s/�•�_ NEW RE9DENTIAL PLMB. SQ.FI'. - Date Recei til
Z Z NOI]CETOAPPLICANTAVaftermakingt teof Gemptlon,you
should bemmesubject to the Workers'Compensation provfalons piths Labor TOTAL:
ccNCode,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl a
,.fth workfrwhtrrebacomtmctlondi(See. agency'Clvc.) perforrry TOTAL ELECTRIC FEE
Z Lende the work forwhichthispermit is issued(Sec.3097,C1¢C. c
V O Lender's Name PLUMBING FEE lwLtw
F Lender'a Address QTY. MECHANICAL PERMIT FEE
O O Icertifythw1havereadthbappllaHonandatatethAthreboveinformation MECHANICAL FEE
comet.is I agree to comply with all city and county ordinances and pate law. PERMTTISSUANCE FEES PAID: _
Nrelatingtobulldingcoustmdion,and hereby authorize representatives of this
I— citytoenterupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costsand expenses which may In any wayaccus AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
against aid Ci nsequenaof the granting of this permit.
AIR HANDLING UNIT(OVER lO,WOCFM) CONSTRUCTION TAX
Sig.tum.fAffii.,uZCsrffmd.r Date EXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBantorfut.m Wildingocupam storeorhandle hacardess t{FATINGUNIT(TO100,000BTU) Date Recei of
material a defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Cade SScalo,25532(a)7 HEATING UNIT(OW11100,000 ITU) TOTAL:
❑ Yes M No
Willtheappllant or tuturewildingoempantuarNulpmem ordevics VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management Distrid2 BOILI:R-COMP 0HPOR 100,0(10 BTU)
4YesI�No
haveread the h QousmaterialsrequirementsunderChapler6.95of BOILER-COMP(OVER 100,"B]U) I s l�
the California Health&Safety Code,Sections 25505,25533 and 25534.1 JUL
1 understand that if the building does not currently have a tenant,that it boy NEW RESIDENTIAL MECH.-SQ-FT.
responsibility to notify the occupant of the requirements wmost met
which b
priorto' f m&a ccu
Aifcsteof Opancy. C*of
Owner or aul
brfiLcd agent I.Kits TOTAL: ISSUED"
OFFICE COPY