22505 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEiRMITNO.
Building Address: 22505
o �- Al fi ,v P
ners a _ f� one: A A
nXp 7,ip Q CITY OF CUPERTINaBU1LDING DIVISION -_ �G� 17
CD ryer� a Lm.No: APPLICATION /PERMIT ( C
@' BUILDI NC -MECPDIMCAL CATEGORY CONTROL
Archuect/Englrunr. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERISSUANCE ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION
I hemyieffirm that l am licensed under provisions of Chapter 9(commene- APPLIA ESRESIDENTWL JOB DESCRIPTION
Ingwlth5e ton7000)of Dlvlslon3ofthe Buslnessand PmfeastonsCode,and my
Banse Isle fullforaand effect. PANELS
Llmnae Cl Lle.a IMTOWA
� l
Date Contractor IDI)� � t
ARCHITECTS E A 10 201.1" MPS SQ. .FLOOR AREA /SQ.FT.
90 Z I understand my plans ahall be used a public records.
O
Licensed Professional SIGNS ELECTRICAL
Q w OWNER-BUILDER DECLARATION
FA arcremSPECIAL CBiCU1T/MLSC
P so., Iheby affirm that Coradors License Law for
following reason.(Section 7W1.5,Business and Professions Code:Any city or TEMP,METER OR POLE INS
cmntywhich requlresa permit W..trod,alter,lmpmve,demolish,orrepair
Y anystmct mpr toib Wuame,alsoregUM iheappUmntforsuchper tto POWER DEVICES
K file a signed statement that he N licensed pursuant to the previsions of the
Ow Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
F�05 sion3ofthe Buslnessand Pm(csslonaCode)orthat henexemptiberefromand VALUATION
Q X11 the Wsb far the alleged exemption. Any Wolatbn of SMba 7RiI5 by any OU7LETS.SWI.fCHESFlJC1.URpS
applicant fora permit subjects the applicant to a civil penalty a net morethan
five hundred dollars($503L NEW RESIDENTIAL ELECTR SQ. STORIES TYPECON91RUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure isnot Intended or offered for
Osale(Sec.7094,Businessand ProfessionsCode:The Contractor's License Law
S does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNIT'S
who doessuch work himself orthrough his own employees,provided that such
improvement are not Intended orelfered/w sale.IL however thebt ilding or TOTAL:
Improvement a sold within one year ofcompidlon,the owner-bullderwill have
th;_p+rden of pmving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with limewd PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law docs not apply to an owner a property who
Wilds or Improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
,}IlLt�Lador(d accused pursuant to the Contractor's License Law. BACKFLDWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See B &P C for this reason
OUTS I QF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N—
• Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP D- DO SCHOOL TAX Y_ N_
1 hereby a((Irm that I have a cedlRate of consent resell-Inure,ora V RECEIPT M
gists D(Workers'Comperuatlon insurance ora artltied ropythereof(Sec. GAS EA.SYSTEM-1 WCAOIALEPS PARK FER Y N
3800,Lab C.) a� —
Po11gN /fir!�� /ZJ cAS FA.SYSTITf-OVFRafFA) BUILDING FEES
.�Certified copy is hereby thrh 1 ity PLANCHECK FEE
Certified copy Is t
filed with the city inspection division. CREASE/INDUSTRL WASTE INTFRCEI'TOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.H FT. Date Reed t#
(ThissMion need nu be compaelM tithe permit Isforons hundred dollars
(5100)or I.) ENERGYFEE Y N
I certify that In the performance of the work for which this permit is hared, WATER HEATER W/VFM/dECIR —
I shall not employ any person In any manner so rome ct to the WATERSYSTEM/TREATING
Workers,Com tion of Gy1lprgp,,p4te PAID
O Z Applicant ss iA hl \XY YO NEW RES[DEN7IAL I'LMB. SQ}7. Date Recei t#
Z O NOTICE CO�A'IT 1 f,a{te ng h Chi erti(Iote of Exemptlon,you
W should become subject to the Workers Compensation provisions of the Labor TOTAL:
c Cede,you most forthwith comply with such provbions or this permitshala be
BUILDING FEE
LU deemed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
ll Z Ihercby orkfohwtheretaconswctlsu lendingagency Cie.
perfornF TOTAL: 0L ELECTRIC FEE
Lender the work for which tion permit tissued(Sec.3097,Civ.C.)
O O Lenders N. PLUMBING FEE . D
LL ~ Lender'.Addre.s QTY.I MECHANICAL PERMIT FEE MECHAMCALFEE
U Icertifythat l have read this application and statethat the above information
O W iscorrect.lagreetmcomplywlthalldtyandcountyordinanasande.telaws PFRMITISSUANCE FEES PAID:
} IL relating to building construction,and hereby authorize representatives ofthis
~ W cit tD entero the above.mentioned for Inspection sn. TER ORADDTDMECH. Date Receipt#
y(We)agree to save,Indemnify an d keep Mem the City of Cupertino —
V
against liabilities,judgments,costa and expenses which may In anywayaccrue AIR LADLING UNIT(TO 10,=CFM) SUBTOTAL: 7�OD
against ai Ity In consequen f the granting of this permit.G&7/ Im CONSTRUCTION TAX
�� /� � �j may/ AIR HA UNG UNIT(OVER 10,000 CIM)
SigAxwu . pp cant/ on tractor Date EXHAUST D(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfamm building occupant store or handle Farardous HEATTNCUMT 100,000BTU) Date Reeel t#
materna as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I{ealth and Safety Cade Section 2S532(a)r HEATING UNIT(Ov 100,000 BTU) TOTAL:
M Yea r!No
Will the applicant or future building occupant use equipment ordevices VW11LATIONFAN(SA LERESID) ISSUANCE DATE
which emit hanrdom air contaminants as defined by the Bay Area AU
. Quality Doitrict? BOILER-COMPptm OR 100, BTU) #,AID
4Yes 9�I No I'��
have read the bazar�oe,material requirement nndw Chapter 6.95 of BOILER-COMP(OVfiR 100,0008 )
the Califemn Health&SofoyCd,Snt..25505,25533and25534.I
understand that lithe building does not currently have a tenant,that itis my NEW RESIDENTIAL MECH. SQFT a� bee
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a CxNficzte of Occupancy. j Q�•
Owner or authorl,md agent Date IOTA ISSUEDBY:, W V v`ULL
L
OFFICE COPY