22325 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 17
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SuameeA C � / r 3 A M A A
CITY OF CUPERTINO-BUILDING DIVISION
G°^tra °:sName: L LI=.N°: APPLICATION ( PERMIT
'Vl VI I U 75
BUILDING-ELECTRICAL-PLUMBING-MFCHAMCAL CATEGORY CONTROL N.
Architect/Engineer. Lie.Lic.NNo o:
QTY ELECTRIC PERMTT FEE
- BUILDING PERMIT INFO,
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby Section that
Divisised on
oftheerprovisions ofssand Pro Chapter
ssions9ds,and c- API'(-]ANCESWiSIDENTIAL JOB DESCRIPIION
' 'ngwith Section70fA)of Divislon3 piths BusinnsandProtessionsCode,and my ,
LicenselClasv'R force
3inG ic.# 7S PANELS w
ARCHITEC'S DECLARATION J
�Z I understand my plans shall be used as public records. OVERIOOOAMPS SQ.FF.FLOOR AREA $/SQ.Fr.
q OC L
m Z U Licensed Professional SIGNS ELECTRICAL ® ' s '
Q 41 OWNER-BUILDER DECLARATION' S 1^v'
SPECIAL CIIiCUIT/MLSC T
1, Z
following
Contractoies Code:icerse,Law for he
FZ O r"pp lollowing reason.(Section 70315,Business and Professions Code:Any city or TpMp METER ORPOLE(NST.
Z1'W� cmntywhichrequiresapermittommtmdalteghnpmvedemolish,orrepair
g . anystm=mpriortoltsismame,a6orequirestheapplicantforsuchper tto ron POWER DEVICES DA
F6J O file a signed statement that he Is licensed pursuant to the pvisioof the - - M. 'a�
Y,
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
F•�Ci sion3 ofthe Business and ProfessloseCois)orthat heis exempltherefromand V ATION�f.
the basis for the alleged'exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than -
five hundreddollars($SDO). SQ.Ff. STORIES TYPE CONSTRUCTION'
- NEW RESIDENTIAL ELECTR
�j.. ❑I,as owner of the property,or he employees with wages r their door
sam(Soc.7K wuldotheworkdentio s[mcture is not Intended o iofferedfar
sale(Sec.apply
to im essow and Profession who
Wilds Committeesoven License Law
don not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
EE
who
provemsuch
ts arework
nrintelfor edothrough his own employees,provided that such
•
improvements tintendneyear foomperod rsale.the oweveg older iiingor have TOTAL:
improvement Menof proving
within he did otbuil porim,thee for purpose
rposerwillhave
t)l vas ower of the p opeity,a build or improve ting with licensed QTY. - . PLUMBING PERMIT - FEE ELOOD ZONE APN
u I,as owner of the property,am exclusively 0Business
contracting with ns Code- PERMIT ISSUANCE
contracTmrs to construct thepmject(Sec.7044,Business and Prdesslon Code: �,®D
The Cmdearme,License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such projects with a FEE'SUMMARY
co,2t.[aIn (s)licensedpursuanttothe Cont.d e.License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Dace re or RFG�I'N
WORKMAN COMPENSATION DECLARATION F]X.T[1RES PER TRA(' SCHOOL TA% Y_ N
hereby affirm that I have a certificate of consent to self-Indo RpCWpI it
certiBcateofWorkers Compenation lnarinceora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y N '
380D Lab C
Policy 3 �`47 DO LZ.— I - RECHIFTIf
Copa.yGAS EA.SYSTEM-0VER 4(EA)
Com anY copy
nLOM BUILDING DIVISION FEES
Certified copy is hereby filed
the city i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Codified copy isfiled with the city inspection division. `
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETIAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thissecti°n need not be completed if the permit is forone hundred dollars
($I06)°rlesda ENERGYFEE Y_ N
ce _
I rtifythat in the performance of thework forwhlch this permit Is lesaed, WATERHEAIFR W/VENT/ELFLTR
I shall not employ any person In any manner so as to become subject to the WATER y-I-STEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ-F . Date Reeei t#
Z O NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you
should become subject to the Workers'Compenatlon provision of the Labor TOTAL:
CCN Code, u must forthwith comply with such rovkion or this permit shall be
� > deemed revokes. P y P P BUILDING FEE
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirmthat there is.contraction lending agency for the nperform- iqlb ELECTRIC FEE
0 Z areof the work(ole which this Is (Sec.3097,Civ.
TOTAL:
LL O Lenders Name - Y PLUMBING FEE
L) Lendenaadan QTY.. MECHANICAL-PERMITFEE'
O W Iced.I hatl agree to e mad comply lith all
aandutyordinances ndstat saws MECHANICAL FEE
rmct.]agreetocomplywithallcttyrebyauhortie preseand statelaws PERMTTISSUANCE FEES PAID:
C relatoenterupontcabove-on,and ioned ebyauthorizereectionpu fives o(this '
W it Wa)are n the,Indemnify and ro (oleins eCit ser, ALTER ORADD TO MECH.
� Z
city p° P pf1h' P P'tpO Date Receipt#
(We)agree to save,indemnify an d keep harmless the City y Cupertino
V against liabilities,Ndgments,c and expenses which may in anywayacrine AIR HANDLING UNIT([010,000 CFM) $DBTOTAL:
against sai ceof the granting of this permit.
8 AIR HANDLING uNri(OvpR]6,000cpM) CONSTRUCTION TAX
Signature of Applicant/Contractor Defte EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apphca nt orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Repel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No
Willtheapplicantorfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which craft hazardous air contaminants as defined by the Bay Area Air -
QualityManagementDistrict? BOILER-COMP(31B'OR 100,000 BTU) Lfs1�,
n Yes nnNo C'PU
`('have read the hnrlr N materials requirements under Chapter 6.95 of BOILE&COMP(OVER 100,000 BTU) -
the California Health&Safety Code,Sections 25505,25533 and 25534. I e l t�. 010
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. F��1N9
responsibility to notify the occupant of the requirements which most be met -
prior to issuance of a Certificate of Compa ncy. /i cop
W�1W Nt�P
Owner or authorized agent Date - ISSUED BY: Y
TOTAL:
OFFICE COPY