22105 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldemlficatlan PERMIT NO.
Buildlr�Addms:
_ � 22105
Name; ane:
a0� �✓�^/ CITY OF CUPERTINO-BUILDING DIVISION
con a ss Name: SNUBS APPLICATION I PERMIT l 6
�V1, T�7�RlYA7oyA� ^/ ��' BUILDING-ELILTRICAI.PLUMBINGMECHANICAL CATEGORY CONTROL#
Arcblterl/Engineer. Lie.No:
/U 2 QTY ELECTRIC PERMIT F,E�EE BUILDING PERMIT INFO
Addrcae: / - fes ( PERMITISSUANCE 1...ai � E] 1:1 ❑
LICENSED CONTRACTO DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commenc- APPLIANCESRESIDENTIAL JOB DFSCIUPTTD. N S7
Ingwith Section 7000)of Dlvlkon3ofthe Bualmdied �w. Profekons Code,and mylicense T7 tR_l�ll�
LLicause Cleo Bf!Cantacior S J��� PANES OF 1 ODate
UP TO 2DOAhU
ARCHITECT'S DECLARATION 201-IODOAMPS
00 I understand my p)am shall be used As public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.Fr.
�d Licensed Professbal SIGNS ELECTRICAL
<t OWNER-BUILDER DECLARATION
G SPECIAL CIRCU T/M 5C
7t, a Ihercbya(Ormlhatlam exempt from the Contractor's License Gwfm the
Firp following reoor.(Sectlon7031.5,Business and Professions Code:Any city or Q
y county which requlresa permittocoruttuct,aite.Improve,demolish,orrepalr QAP.METER OR POLE INST.
3
fade
pMrto Its Issuance,alsorequlrnthe applicant for permit to
fade a signed statement that he Is Bansed pursuant to the pm f Rm of the POWER DEVICES
Ok Contactor.License Law(Chapmr9(co.miogwilh Section 7000).f Owl.
COs kon3ofthe Buslnessand Profmnb Code)oethk helsexemptthercfromand SWIMMING POOL ELECTRIC }� `, VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETmmSSWITCHESHXTURFS (� Ov' d Oa
G5 applicant for a pedbaubjects the applicant to a civil penalty of not room than J
live 1,as o nerdolof he pr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I•as owner of the property,or my employees with wages r thele sale
compensation,le&cthe Code:
h not Intended oroffered for
O ole(Sec 7044,Business and Pro(esioa Code:The Contnetofs Llcenu Gw
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
whodoesauchw.rkhlmself orthrough hisownemployns,provided thatsuch
improvemeno are notIntended oro(tered fora&.If,however,the W tiding car TOTAL:
improvement Issold within one yearof completion,the owner-bullderwlll have
tlgkurden of proving that hedid not Wildorlmprove forpurposeofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract.m to construct the project(Sec.7044,Business and Professions Code:
The ContaRor's License Law don not apply to an owner.!property who ALTER-DRAW&VENT-WATER(EA)
WIWs or Improve thereon, and who contracts for such ptojacs with a
ogDSfa&or(.)Itcensed pursuant to the Conlractoe.License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under Se. B k P C for this reason
DRAINS-FLOOR ROOF,AREA,CONTI. SANITARY Y N
. Owner Date RECEIPT If
WORK MAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI-1001.TAX Y_ N
01 hereby orflrm that I have a l n me of consent d spy theurc,ora RECEIPT N
MOD,
of Workeri Compevatlon]vurence oracertlfled copy thereof(Seo. GAS EA.SYSTEM INCA OUTLETS PARK FEE Y N
Policy
Lab C.)
Paltry# GAS RA.SYSTEM-OVER 6(EA) DNG DI N
om any BUILDING DIVISION FEESC
Certlfled copy Is hereby turnIs
Certlfied copy b flied with the city
Impaction division. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� ty
CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MOVE. Date Recei t#
(Thissection need not be completed lithe permit Is forom hundred dollars
(5700)or less.) WATER HEATER W/VENT/ELFCTR ENERGYFEE Y—' N
I certBythat in the performanceof the work forwhlch this permit le Issued, _ —
1,hall not employ any person In any manner soo to become subject to the WATER SYSCLM/TREATING
Workea'Compensatlon Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Dale Revel t#
Z If,after making that Certificate of Exemption,
O NOTICE TO AI'1'LICANT:
Fshould became subject to the Workers'Compematlon provislom ofthe Labor TOTAL:
Code,you muss forthwith comply with such provatlom orthls perentahallbe
IL >a dm
eeedrevoked. BUILDING ELE.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE t
I herebyaBlrrnthzt there Is a construction lending agenccyy for the perform ELECTRIC FEE
D Z ance of the work for which that permit is Issued(Sec.3097,91y.C.) TOTAL
U O Lender.Name PLUMBING FEE
LL 1=s Gndcr.Addres, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythet l have read this appllationand statethat theal welnformatlon ,
4 Is comed.Iagree to comply with all city and county ordinances and Nate laws PERMIT ISSUANCE FEES PAID:
N talking to building construction,and hereby authmilu reprasentativesofthIs
F Z cltyto enter upon the abovo-rrentbned property for Impaction purposes. ALTERORADDTOMECH.
Z (We)agree to ave,ledemrdfy an d keep harmless the City of Cupart Ino Date Receipt#
against liabilities,judgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,1100 CFM) SUBTOTAL:
against.ald CityIn uence of egrenting pf bpetml4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gafilreofAt/Coktrfictor Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT 00100,000 BTU)
material as defined by the Cu petition Mu nicipal Code,Chapter 9.1 2,and the Date Recel t#
Health and Safety Code Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL: CIA
0 Yea No
Will the appliontor tore buildingompant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hoard...air wntamianb as defined by the Bay Area At,
QualitYsneagenant No BDB.I(R-COMP OHP OR 100,000 BTU) PAM
4havercadthe hazar ouamaterials requirements underChapter6.95of BOMER-COMP(OVER100,000BTU)
the Callfmnla Health&Sifky Code,Sectba25505,25S73and25534.1undersla'IAI ^^�
re,Portandthat if thenote Wilthe occupant of
not the
encs tenanwhich that It Is my NEW RESIDENTIAL MECH. SQ.FT f F,`,
reser to issuance
Ity ce notify the occupant of the requlrcmeno which must be mct
prior to Issuance of Certificate of Occupancy. '
fl•.IuvV r"'�I�....`
Owner or authorized agent Data TOTAL: ISSUED BY: \oW
OFFICE COPY