22354 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PEILWTNO.
Building Address: _ 22354
Phone: p A p
cane : CITY OF CUPERTINO-BUILDINGDIVISION ��-2-� q,
ff—
Comractor's Nm
ae: - LIc.No: APPLICATION) PERMIT —
'NJ a �� BUMDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTjIOILYPr'�1
Architect/Engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Addreae: APPUA CFS- CE [T
LICF.NS ED CONTRACTOR'S DECLARATION
I hereby ion 700hatlam Bcm3oftheerprovbiono(Csuorts9(mmmmc APPLIANCESRF_SIDEMIAL ♦ JOB DESCRIPTION
inense I,in fall forecast!di n3o(th.-Businessand Pro(essionsCode,and my ` _ � OD�
license Is in full forecast!effect sip .PANELS /��-r�..��(� 6//`fl°J–t/��- `
Lic ss Llc# S8 Qct l{' �' `--'a`�' t
ale ConLactor UitO YttwfUP TO 200 ANTS
ARCHITECTS DECLARATION 2014000 AMPS
Ore 7 I understand my plans shall be used M public re ordd OVER IWO AMPS SQ.FT.FLOOR AREA $/5Q.FT.
CO /��
z() Licensed Professional SIGNS ELECTRICAL I"lQ I yt/1?�
6�n OWNER-BUILDER DECLARATION SPECIALCI(CUIT/MISC
Z�r^; Ihereby affirm that lam exempt form the Contractors License Law for the / d,�r�
9 following reason.($¢ction 7031S,Business and Professions Code:Any city or "1
O/t_ TEMP.METER OR POLE)NST.
county eture requires a permit to construct, athemprove,demolish, eom.t hr
4'< anystructure prlorto its bsrance,also rcquiresthe appllant(or such permit to POWER DEVICES
U file a signed statement that he is licensed pursuant to the provisions of the LAa.a
e`o5Contractor's License Law(Cha erg(commencing with Section 7000 of Divi- • L 1 N v
sion3ommftheBusinessandPionsCods)orthathebexemptthereformand SWIMMING POOL ELECTRIC y t
the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLETSSWITCHESFIXCURES
appbc.nt Tara permit subjects the applicant to a civil penalty of not morethan
p five hundred dollars($500). NEW RESIDENTIAL ELECTS 1 as owner of the properly,or employees with wages as their sole `SQFr. STORIES TYPECONSTRUCTION -
❑, p perry, y emp oye g
C%Q compensation,wlliclothe work and thestmcturebnot Intended or offered for
$ O sale(Sec.704A Business and Professions Cade:The Contrectoes License Law
F�1 $ does not apply to an owner of property who builds or improves themes,and
.5^ who does such work himselfortheough his own employees,provided that such NGM.
improvements are not intended orof(ered forsale.ILhmevepthebulidingor TOTA a
Improvement issold within meyearu(completion,the ownerbullderwlll have0 NA
th�rden of proving that hedid notbuildorbnponeforpurposeo(sale.). QTY. PLUMBING PERMIT - FEE 1.
L as owner of the property,am exclusively mntrae ing with licensed PERMIT ISSUANCE 7
' contnctam to construct the project(Sec.7044.Business and Protessbm Code: DATE I ( 2�
The Contractor's LTanse Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATFA(EA) _
builds or Improvmn
Improves thereon, and who neras for suers pwiects with a FEE SUMMARY
J1 actor(s)Iase
nd pursuant to the Contrct
aor's License Law. BACK FLOW PROTECT.DEVICE
5I am exempt under Sec B k P C for this reason
OUTSIDE FEES
DRAINSFLOOR ROOF,AREA,COND. SANITARY Y_ N -
• Owner - Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirmorksr that I have ocertificateIns c of consent to self-hours,ora RECEIPT#
MOD,
of Workeri Compensation Insurance oracertilled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS ARK FEE Y N
3800.Lab CJ RECEIPT#
Po11ryX GAS FA.SYSTF2d-0VERd(EA)
Com any BUILDING DIVISION FEES
[3copy b herebyth the city
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b tiled with the city Inspection division. �],t'�},+�a
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID � ab
COMPENSATIONINSURANCE SEWER SANITARY STORM EA 200FT Date Receipt
(Thlssection need nae bs completed if the permit b foron hundred dollars
(8100)or less.) WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y_. N
1 unify that in the performance of the work for which this permit Is Issued,
I shall not employ any person in any manner so as to became subject to the WATQt SYSIFM/TREATING
Workere Compensation lawsof Californla. Date PAID
OZ Applicant - NEW'RESTDENTIALPLMB. SQFT. Date Recei t#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
t 2 should become subject to the Workm Compensat ion provision of the Labor A
CC W Code,you=at forthwith comply with such provision orthb permit shall be BU DING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
FEE
CL Iherebyafim.,that them is a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ance of the work for which this permit is bsued(Sec.3097,Civ.C.)
02 Lenders Name - - PLUMBING FEE
LL t- Ursice.Addeas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
1arti(ythatl have read thisnfo li.
application and statethat the.1swew
O W
a. limrrect.Iagree to complywith all city and county ordinances and state Taws PERMIT ISSUANCE EES PAID:
t r relating to building mntroctton,and hereby authorize representatives of this _
(— U) city to enter upon the above-mentioned property for inspection pu rposes. ALTERORADDTOMECIL
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against Babihties,jadgerma,,costs and expenses which may in any wayacmeAIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
t AIR HANDLING UNTO(OVER lO,OWCFM) CONSTRUCTION TAX
7/471f L
Sigruturc of Applicant/Contractor Dat _ EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)' ` Date Recei 1
matedzlasdefined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)t HEATING UNIT(OVER 100,W3 BTU) TOTA
❑ Yes No
Will the applicant or tuturebullding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaMrunts as defined by the Bay Area Air
Quality Management Distria7 BOILER-COMP OUP OR 100,000 BTU)
4YesFF��No
haveread the ha Yus materials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
Ne Callfornialiealth6Sa(sty Code,Section 25505,25533 and 25534.1 t j n
1,yq9�
Ii understand that lithe building does not currently have a tenant,that it k my NEW RESTDEN"IIAL MECH. SQ.IT. �CI H.
responsibility to notify the occupant of the requirements which most be met /a� T
prior to Issuance of a Certificate of Occupancy. (.�►y$�C.pII
HY
Owner or authorized agent Date. _ SSIIEDBY:
TOTAL
OFFICE COPY