22561 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22561 n C al
3 Woo Dr, o I
aa one, A
�O k AJ / CITY OF CUPERTINO-BUILDING DIVISION
Con�or's Namen—.s� . Lie.Na: APPLICATION It PERMIT
fJ'�u»+ 29 ] BUILDINGELECTMCAL-PLUMBING-MFCHANICAL CATEGORY CONTROL If
� ArcMte /Gg lir. Lk.No: -
q QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
AddrelV 6'- ,RACTG I CLARATLPERMIT ISSUANCE
LICENSED CONTSDEON 1:1 El ❑
I bereby arflrm that l am licensed under providon.of Chapter 9(communc, APPLIANCES-RESIDENTIAL ]OB DESCRIPIION
ing Mth Sedion7000)of DlWslon3ofthe BuAnessand PmfemionsCode,and my
Brave b In full(o end died. PANELS
I.imnse Cl m LmM LJV
Date GOnhador 201-1000 AMPS
AUP TO 200AMM
RCHITECTS ECLARATION
9z I understand my pizv shall be used as public rec rd& OVER 1010 AMPS SQ.FT.FLOOR AREA $15Q.FT.
O
Licensed Profeadamal SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
rn a SI'CCIALCEICNT/MISC
owingrmson. thatlamexemptlro es he sad Profdor's License Law fart be
QQ following reason.indican permit
to Business and Professions Code:Any city it
0 1"'� county which rcquiresa pertNt tomrutrud,alter,Improve,demolhh,orrepalr TEMP.METER OR POLE[NST.
any structure price to its Issuance,also requlers the applicant for such perrot to
[5 file a signed statement that he h licensed pursuant to the provhlona of the POWER DEVICES
O S Contractor.License Law(Chapter 9(commencing with Section of Dlvl- SWfi;${[IJG}Ul9L 6QC'FWC ��, VALUATION
elan 3 ofthe Business and ProfessioruCode)or that he h exempttherefrom and s
Q the bash far the alleged exemption. My violation of Section 70313 by any OIJILE•ISSWI.I.CFIFSA cXfU(i'ES a Qa��'
applicant fora permit subjects the applicant to a dWl penalty rind more than 3
five hundred dollars($50(t). A g f�
"W NC RESIDENTIALEEITTIR
Til (^n
E]1,as owner of the property,army employees with wages as their dole STORIES TYPE CONSTRUCTION
C rots CS.. 0K Busuarm workand thea Cdurehnotantract ear offeredLaw j
doe(Sec.et apply
to alnow owner
Profembv Code;The or imp dols Lt.es berme Law
does eassucly torn ower ofproperty
rough who nem orimprwvided thatem,and _ OCCGROUP RES AMTS
M
who
preve encs are not mself or dedomugh his own le.If,however,
ch or
Improvernan irannot Intended earofco fornale.IL ca ever,lheerlldingv TOTAL:
Improvennnthsold withmaneycaro(complctlan,tbeowner-bu0derwWhave '
OW-Itarden of prancing that he did nm build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
jJ L as owner of the property,am exclusively mntrading with Ikensed PERMIT ISSUANCE
contractors to mvtrud the project(Sec 7014,Business and Professions Code:
The Cmd.dorb License Law does not apply to an owner of property who ALTER-DRAIN 4 VENTWATER(EA)
Wim.or improve thereon,theren
o ,and who ce tram for ouch p - -
rojects with a FEE SUMMARY
cg0tt mrh)11...d pursuant to the Cantraaor'e License Law. BA W T. C
LJ I am exempt under Sec- B It P C for thb reason _ _ a OUTSIDE FE,;,
Owner Date DRAINSPLOORROOF,AREA,jODND. SANITARY RFLEE7P
OF
WORKMAN COMPENSATION DECLARATION FI%T(JRFS PFR TRAP i SCHOOL TAX Y_ N_
I hereby affirm that I have a certificate of consent to self-Inwre,ora R . „u 1. � RFLEBxr M
rtlBrale olWorken'Compewuon lesurancam.certified copy thereo((Sec. GAS EA.SYSTEM-1 INC.g OUTLET'S PARKFEE Y N
3Bro,L.bc.) /05�90(2�3 RECEExra
Poliry M_
Com anv �y �"�4dld GRR'B'l �� BUILDING DIVISION FEES
C7CertiRed copy herebyth thhN. GREASE/WDUSIRL WASTE INITWEPTDR PLANCHECK FEE
'�CenWed copy b filed with the city IvpeMon dlvlelon.
Y" se-
CERTIFICATE OF EXEh1PT10N FROM WORKERS' GREASE TRAP PAID ( �
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA Z TFT Date Recei tit
RNdsecllan need not be completed lithe perMt h for ons hundred dollars
($10D)vlcss.) WATER HEATER W/VENT/ELI:CTR ENERGYFEE Y N
I certlfythat N the performance ofthe work forwhlch this permit is issued,
I shall not employ any person In any manner an,as to become subject to the WATER SYSTEM/TREATING f
Workers Compensation La a..f Ca Wamh.Data
PAID
Z Z NPOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr.plicard Dale Recei IM
O should become subject to the WorkersCompensation provisions ofthe Labor TOTA
~ N Code,yma at forthwith comply withsuch provhlov orthh permit shall be DING FEE
LU > d«mea revoked.
0. c CONSTRUCTION LENDINGAGQJCY SEISMIC FEE
I hereby afBdnthet there h e mvtvdlou tad&c. agenry for the perform- ELECTRIC FEE
Q O armee.'. work forwmch fish perMthhnmd(Sec.3097,Clv.CJ
TOTAL:
() lender'.Name PLUMBING FEE
14, E Lender's Address QTY. MECHANICAL PERMIT FEE MECHAMCALFEE
O 111
Icertlfythatlhavereadthu.ppBmtbnandatatethattheabovelnformation
a broned.I agree to comply with all city and county ordinances and Aate laws PERMIT ISSUANCE FEES PAID:
>. relating to building conatrualon,and herebyauthorlurepresentativesofthis
(—
city to enter upon the above-mantloneinspection property for inspection purposes. ALTERORADDTOMECH.
Z mDate Relies fp
V _ (We)agree to save,tndeNfy an d keep hamJB.s the City of Cupedlno
against liabilities,Pdgnamo,mdsand expenses which may In anyway accrue AIRHANDLINGUMT H010,0(IOCFM) SUBTOTAL:
against mid City In consequence of the granting of this permit
aRI{ANDUNCUNIT(OVER Io,DDOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous HFATING UNIT 00100,000 BM Date Recei Ip
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Code dion25532(a)7 HEATING UNIT(OVER 1W, BTU) TOTAL:
❑Yea . V 000 No
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eMt hazardous aUmntaminantsm defined by the Bay Area Air
Quality Management District? BOILER-COMP(3M'OR 100,000 BTU)
4Yes No
havereadtheha.u.matcdalsrequirementsunderChapter6.95of BOILER-COMP(OVER100,000BTU)
the Glifemia Hcalth k Safety Cade,Sections 75505,25533 and 25534. I
u ndemta nd that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT ll�nfk
mapovlbility, d
to notify the occupant the requirements which=at be met FY
prior to Issuance d aCe0 m'eo( avpery
n .
/ CNy I
Y Y tar
O�cr o,authodud TOTAL: v—
agent to ISSUEDBY:�Z IY(/
OFFICE COPY