22292 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IdentlfbtlonPFRMITNO.
Buidin'i s—o s-r-4 �-�,� ��. 22292
ame. one: A A
♦Vi ' CITY OF CUPERTINO-BUILDING DIVISION
ontractor's Na Lnc.Nex APPLICATION / PERMIT
BMDINGELECMCA4PLUMBING-MECHANICAL CA7F-GORY CONTROL#
Architect/En ser. Llc.No:
'�\/�A� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre9Sp`-a
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hthSy .fimnthatlam Bcen3oftheunder ne blonsaf Chapter9dm,..d c- MI'L[ANCESRESIDENTIAL JOB DE IUTIION
fican hSection 7000)of Dlvislon3oHheguslnessandlhvfnsionsCAde,and my
license Is In u ` and dfect. // PANELS N"� _,
License Class Lic.p T.� J✓.T.,}'-71�
Data Contractor_
ARCHITECTS DECLARATION 201.1000AMPS
q�+0 G7� I understand my plans shall be used m public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
i4 Z(� Licensed Professional SIGNSELECTIUCAL E D I #
6 OWNER-BUILDER DECLARATION SCIRCUT/MISCT/M15C
t, owing yasorm Sectioth.tl731.5.4emBne from the Contractor's Code:lmnac Law far the UTE R
70..'� following reagn.(Section 70(1.5,Buslnem and Profemions Code:Any city or 7
O Z Fµ9 R POLE INST.E countywhichrequlmsaperMttocomtnuuirest caprovgt forsuch,ermitto Y�S anyassigned tatepriotents hathe beli orequlrestuant to the pro inions of t e'S C aS Rte a signed sicens eLa that he t r 9 Eco d pursuant to the tion 7000) of the Ho' Contractor's LlcemeGw Cup erg(comma ng with Section 700p)of Dvl- L ELECTECOn aton3ofthe Business and ProfessionCode)orthat he V exempt therefromand yJthe basis for the alleged exemption. Any violation of Section 7W1.5 by anya liontfora rmlt sub'cts thea licant to a civil nal ofnor more t hon t HESFIXTURFS E
p five a PP a ty C7CJ O CJ(
E]1,as
dollars he pro NEW RESIDENTIAL ELECTR
? pas ownerof sheproperty,or my employeewith wages r their sale SQ.FE STORIES TYPE CONS[RIX:TION
<
compensation,0K will do the Bushes,an rk,Pr and the structure Code;The
Intended License
ed for
Law
O sae(Sec.apply
to ainow and property
Code:The Commcrimproves
mp eves Lkeme Law
s� don not apply torn imserofprough who builds nempoyees,p vested ons,that and
such
who does such work arenotmtandedelfor mattered ovale.If yees,providedthatgre OCC.GROUT' RES.UNITS
Improvementsared withinonerarfcomor lokth hmveveg deer ill have TOTAL: `
Improvement Lswld within one yearofcompletlon,the owner-bullderwlll have
19
te rdenof provingthat he did not build orimpove for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD7ONE ppN
L as owner of the property,am exclusively contracting with licensed pFRMrf ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contactors Llrense Taw does not apply to an owner of property who rz CV
ALTER-DRAIN Wilds or Improves thereon, and who contracts RAIN&VENT-
for such pitapeta with a WATER EE-A)
,,RRSS((aaw
ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this ren
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N-
• WORKMAN COMPENSATION DECLARATION RECEIPT#
hereby affirm that I have a cartificate of consent to self-Inure,or a FIXTURES PER TRAP SCHOOL TAX Y N
m iflate of Workers Comperuationlmumnmoramni(e mpythemo((Sec. RECEIPT#
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N RECEIPT N
Co ny CAS EA.SYSI'EM-0VER4(EA) BUILDING DIVISIONFEES
�Certlhdd copy R hereby th the city
❑CertNed copy bfiled with the city Inspection division. GR[ASE/INDUSfAI WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlssectlonneed net becompleted lfthepermt isforone,hundred dollars SEWER-SANITARY-STORM EA.200FT. Date ReCel tit
(S100)orlessd WATER HEATER W ENERGYFEE Y N
I ll not that in employ
he any person
i anf the work to as to E ser permit B issued, /VENT/FT,FCTR
I shall not employ any person In any manner at a to become subject to the
Workers Compensation lawn o/Gllfornla.Date r ATTR SYSTEM/ TING2aC�J
O Z Applicant PAID
Z O NOTICETO APPLICANT.If,after makingthks Certlflateof coffin you NEW RESIDENTIAL PLMB.__SQ,FT Date Recei t#
Fshmld bdcomesuby to the Workers Cempensatlonpmviaiem oft he Labor TOTAL:
N Code,you must lorthwithmmply with such provklons or this permit shall be
W 9 deemed revoked.
W G BUILDING FE a tO
CONSTRUCTION is a ON LENDING AGENCY
CL Ihercbyaf@mthwhJchtbacomwctienlendegagency 7,Civ. .) perform. SEISMIC FEE
Q Z Lander'sNwork(orwhichthb permit OLsgdd(See 3097,CIv.CJ 1I/ ELECTRIC FEE
TOTAL "I`
U O Lender's Name PLUMBING FEE
ly U ender's Address QTY. MECHANICAL PERMIT FEE
O W Iredifythatihave rcadthb appBatbnand eUtethattheabove Information MECHANICAL FEE
S hummer lagree to comply with alldty and M ordinances and state laws PERMRISSUARCE 2� FEES PAID:
} N relating to building construction,and hereby, thorize am
F Z city to enter upon the above-mentionedp rty for Impaction purposes. ALTER ORADDTOMFCH.
(we)ogee to save ndemnlfy and cep harmless the City of Cupertino Dale RCCCIPIM
against liabilities,p menta, ea expenses which may In any way avenue AIR HANDLING UNIT(TO 10,00p CFM) SUBTOTAL:
against.] tY conseq ingofthispennit.
e -T AIR HANDLING UNIT(OVER Io,"Cr•M) CONSTRUCTION TAX
Signature of AppRcent/Conacmr Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wilitheapplicant orfuture budding occupant store or handle hazardous HEATING UNIT(TO1N,O)OBTU)
materialasdeined by the Cupertino Municipal Code,Chapter 9.IZ andthe Date Recei ted
Eleahh and SafetyCade Section25532(a)? HEATING UNIT(OVER 100,000 BM
❑Yes M No TOTAL: 4
Will the applicant or future building occupant use equipment or devices VEN71LA770N FAN(SINGLE RESID) (k ISSUANCE DATE
which em t hazardous air contaminants as defined by the Bay Area Alr
Quality Management District? BOILER-COMP(3EE'OR100,000BTI1)
RYes II""��Na (!`h��
have read the hazar�io smatedals requirements under Chapter 6.95 of BOILER-COMP(OVE2100,000BTU)
the Celifomia Health&Safety Code,Sections 25505,25533 and 25534. I JUN 0 X91
undersiand that if the build Ing does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FL
responsibility to notify the occupant of the requ tremens which must be met
Prior to Lssuancd of a Certificate of pas pa ncy.
6118 0f CUparti0n
Owner or aulhodzed agent Data Le
TOTAL: tS ISSUED BY:
OFFICE COPY