22157 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Pro Identiflrefim PMWTNO.
Bug Address: ar `- 22157
rs sone: one: APPLICATIONSUBMULALDAlh�j
� _l4 CITY OF CUPERTINO-BUILDING DIVISION
V Nanr
c rI sbcog �s .No: APPLICATION / PERMIT J
BUrLDINCELECTRICALPLUMBINGMECHAMCAI. CATEGORY CONTROL
Amhiten/Fsgtnsem Lit,N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ N ❑ ❑
LK:ENSEOCONTRunder SDEC TION
I hereby aHbm Out lam liesed under pnwLd sol Chapler9(mnmren APP[1AIJCESRESIDFM-IAL JOBD N
Ingwlth5eetbn700A)of Drvlelon 3ofthe Buelnm dPr feae..Cede,andmy
lke..b m fuU force and dfeR PANELS
Llcen Claryy LIc.I
Date %1l Contractor
ARCHITECTS DECLARATION 201-IODDAMIS
rcO L2, I understand my plane shall be used!as public mou d> IOVER100DAMPS $/5Q.Ff.
rj Licensed Prdestonal SIGNS ELECTRICAL w
DINNER."m
DECLARATION grppALCpiCU1T/MISC d V4 O
IherebyellrrnlhelNmeaempt from the Contractors License Lew for the r ,
7 followNg reason.(Section 70715,Bushes ant Profubru Cud,.Any dty or
POWER METER OR IDLE INST.
muntywhlch rcqulrcs•pemdt io mnswct,W e,lmpmvq demokah,orn!perTEMPv 'V
q'y any etncturc prior to ltabmarce,alw mrylmtheappllrent(m each permit to
L�[ NWFR DEVICES /
C fire a signed statement thaf he e,U¢nsed pursuant to the provbbns of the
Or: Contrmore License Law(Chapter9(commencing wkh Section 7000)of Divi-
30�' sbn3ofthe BusW dr'rofms mCode)orNathebeu therefromaed $W NG POOL 171 14 ALE '
ATI
H 5; the basisfor the alleged exemption. My v oieit n of Section 70715 by any OUTLEISSWIICHESEXMiES
M� >5 sppUnant lora pmdt subjects NaappUcanitoactWl pevky of mat mo¢than
q
live hundred dollars 05W. NEW RE&Dw IAL ELFC771 SQ}T, NSI}tl1CI70N'
g
l'J
El 1,ae owner of the Property,or my employees with wage as their sole.
mmpensatlon,wRldothe work andthe structure b wt Intended or offered for
sale ESL.7011,Buemas and PmlmWm Code:The Contactors L¢nse law
doe rot apply to an owner of property who builds or improve thereon,and
c- who doessuch work htrme0orthwgh his own employees,pmvWed that such
Improvemerds art mat Intended m.fifered for sale.If,howewr,the Wilding or TOTAL: t
Improvement bsold wUhinorcyearofcomppletWn,thewvner-0uilderwW law
t Nenofpro gib MdWn buUdorimpmvef¢purposeofsale.). Cry. PLUMBING PERMIT FEE
�I,e owner of the property,am eacluelvely contracting with licensed ROOD ZONE APN
cmiVactorato mruwctthe proJM(Sec 701♦,Buelnesandl'rof.W.Code: PFRMTTL%UANCE
The ContrsRors License law don not apply to an owner of property who
Wilds or Improve thereon,and who mMram fee such projects wish a ALTER-DRAIN&VENT-WATER(EA)
rp4aetor(e Boned pursuant to the Cormmcters License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B& P C for this reason
OUTSIDEFEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner - Date RFCEPI'I
WORKMAN COMPENSATION OE Caren TLON FIXTURFSPERTRAP SCI pOLTA% Y_ N
❑I hereby arum that I haw acertificatelof consent to selfdnarrt,ora RECEIPT if
3W0,Lseo(Wor4as'C¢npematlon lyduranceora certiflad ropy therto(fSec. GAS PA.SYSTEM-1 INCY OUTLETS PARK FEE Y_ N
Polley Nb CJ REC=N
Polity I GAS EA.SYSTEM-OVER 1(PA)
Cam ny BUILDING DIVISION FEES
❑wCertifed ropy b he d with the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑cerulea ropy b moa with the sty Inspection ahnren.
CERTIFICATE OF EXEM PE ION FROM WORK ERS GRE'A'SE TRAP PAID
COMPENSATION INSURANCE sEwewsnNn.nRY sroRM EA moF7' Date Retcl t#
(hh;s ino need not becompleted U the permitbforom hundred dollars
8100 a') WAMHFATERW/VENT/EECTR ENERGY FEE Y_ N_
I¢rtrUky fytthat In the perlonrun¢of the w¢klorwhich this permit b lewad"
I orlu mat.r pees any pensan f any manner ad u m become ubj t to the WATER SYSTEM/TREATI S,
wrelApplice enmpensatwnla.w or Guromh. Date PAID
O Z NOT7Cnt NEW RESIDENTIAL RMB. SQ.FT. Date Recei t#
Z O should beonrRTmtot a orlmi'ComhbCmUhteis Faempmn;yw
ahold bwma subject to the WOM1en'Compensrtbn provisions of the labor TOTAL:
P
N Code,you mux fort hwith comply with such provision,or this permit shall be _ BUILDING
W >
deemed revolved.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC ME
a Ihembyafflrmthat there bamnstroctlon lendingagency fortheperfornt ELECTRIC FEE
Z arm of the workfor which this permit is baued(Sac.30Y7,Civ.C) TOTAL:
(.) 0 Tenders Name PLUMBING FEE
LL h Lenders Adan® QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Irertifythailhawreaithbappkabonedatatethat theabow Wformation
1 bcoree
ron .lagtocomplywkhaUcityand¢untyordW anddatelaws PERMIT ISSUANCE FEES PAID:
>. N relatl�lo bulMWg mnstruedion,and herebyeithortee represnvelw ofthis
F ehytoentarupon the abov rruntloned property for Wpeobn purpoexn. ALTIRORADDTOMECH.
? (We)agree to saw,InEcmrdfy an d Deep harenles the City of Cupertino Date Recel t#
V agaWt WbWtrn,}rdgmente,mslaard erpmes which maylnanywayamue AIR HANDONG 11MT(TO 10,0)0CPAn SUBTOTAL:
aga WtsaidC Immnuequen¢of hegardingofthispemdt.
5.13 AIRIIANDL1NGUNI (OVEc1O,a CPM)" CONSTRUCTION TAX
Slg rare of Appheart/Cf5rdractor Rae D(IIAllS'r EiODD(W/rium CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applant or future building occupant More or hard le hazardous HEATING UNIT(TO 100,0D)BTU) Date Recei t#
material as deflud by the Cupealno Murddpe Code,Chapter 9.12,and the
Fk❑alt Yannd Safety Code Section 2S32(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: t
Wet No
llltheappllant mfvturebillding.pantueeequpmuumdry VENTILATION FAN(SINGLE RF9D) ISSUANCE DATE
whkh emit haardous atr contandrunts as deflmd by the Bay Area Air
Quality Management Dbtriel7 BOILER-COMP Ol IPOR 100,000 BTU)
Ye, QNo
haw read the havrdous mteriab requirements under Chapter 695 of BOILER-CO14P(OVEt 100,000 BTU)
the California I lealth&Safety Code,Sections 2550.5,2 13 and 25511.1
urdmtandtMttfthe WgdNgdoewtcurmntlyhaveaten,ntthatitb.W NEW RESIDFMIAL MECH. SQ.F7 � �
lau
repn,ibaky to notify the ocent upaof the requircnt
men whisres
h at be net ^ y
priertoanceofa Cert1fateof Occu 'Iprcy. A .` 7 ?.
Owner or authodad agent Date 1 BY:
TOTAL
OFFICE COPY