22802 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification C PERMIT NO.
Bu llding Add ross: I ( /p 171 .7� n n O O
'/O 13 /. ti ✓ ..vI1V " 2K 228
w/n�ers ,tant� e: one: A A A
�+ -y/0/V'6- 7 LS-- l I L CITY OF CUPERTINO-BUILDING DIVISION
contradn.•,wme: Lie.No: APPLICATION / PERMIT
C/ BUILDING-ELFCTRICALPLUMBING.MECIIANICAL CATEGORY CONTROL N
Architect/Engineer. Lie.Mo: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERFBTISSUANCE (Q
LICENSED CONTRACTOR'S DECLARATION l�S
I hereby affirm that l am licensed under prwolonsof Chapter9(commere APPLIANCES-RESIDENTIAL DF RE'fION
Ingwith Scctton7000)of Di islon3ofthe Businessand ProlesslonsCode,and my
license Is In full form and effM. _ PANELS
LicenseCuass_A_Lic N s PnOV/i
Dale ContractorUP TO 2�AWS
ARCHITEC7PS DECLARATION 201-I0DOA.MPS
M I understand my plans shall be used as public records. OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.F7.
200 Licensed Professional SIGNS ELECTRICAL
m OWNER-BUILDER DECLARATION "6S`te El SPECIAL CIRCUIT/MISC
7p, z I hereby affirm that lamexempt fromthe Contractorb Limnse Law for the
pp following mason.(Section 7071S,Business and Pmfirmions Code:Any city of
6 7.1-� TEMP.METER OR POLE INSf.
qSI countywhichrequlresa permittocontruct,alter,Improve,demolish,orrepsir
� anystructure priorro Its Issuance,also requires theappllwnt forsuch permit to POWER DEVICES
Ep� V file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with Section 7OWO of Divi- SWAfA9IJC POOL ELECTRIC
O sion3o(the Businenand Profmlom Code)orthat heb esem therclromand A UATION
^S G the basis for the alleged exemption. Any violation of Section7031-5by any �.OUTLETSSWITCHFSHXTURES
applicant for a permit subjects the applicant to a civil penalty a not more than ClY
live hundred dollars($SOOT.
I,as owner of the NEW RFSIDENTIAL ELECTR SQF7. :sEORIFS' EC TION
tf 7 ❑ property,or my employment in with wage as there sole .. .-_.
rompensation,willdo the work,and the structure is not Intended or offered for /�
C O sale(Sec.7044,Business and Profeniom Code:The Contractola License Law I\ f i
$ does not apply to an owner of property who Wilds or improves thereon,and
who don such work himself or through his own employees,provided that such OCC.GROUP
Improvements are not intended or offered for sale.If,however the building or TOTAL: DATE
Improvement nsold wlthinoneycarofcompletlogtheowner-bul)derwill have
thburden of proving that he did not build or Improve for purpose of tale.). QTY.
M PLUMBING PERMIT FEE FLOOD LANE pp
L as owner of the property,am exclusively contracting with licensed
rontranon to ronstmct the project(Sec.7014 Busmesn and Pmfess4ms Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improve, thereon, and who contracts for such pto"with a FEE SUMMARY '
m tractors)licensed pursuant to the Contractor's License Law.' BALI(FLOW PROTECT.DEVICE
f I am exempt under Sec B&P C for thin mason DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RpOplpp q
WORK MAN COMPENSATION unifi ON DECLARATION FDCTURpS PER TRAP �1�t� SCHOOL TAX Y_ N_
❑(hereby affirm that I have o certi@ate of consent to op thereof
or Ly RECEIPT#
certi(icateof Workers Compensation Insurance oracenifled ropy thereof(Sec.
3500lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
, —
RECEIPT N
CAEA.SYSTEM_OVER 4(EA)
Com any Qf S BUILDING DIVISION FEES
CenlEed copy is here fumiahed. a GREASE/INDUSIRL WASTE INTERCEPTOR PLANCf-IECK FEE
Certlfied copy bfiled with the city Inspection division. - /A "1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSpNTTARYSTORM EA 2)OFT Date RCYCI I#
(Thlssenion need not be completed if the permit R forom hundred dollars
($10o)nrless.) - wA HEATER W/VENT/ELLCTR ENERGYFEE 'Y N
Icertify that in the performance of Ne work forwMch this permit Is issued, - a{.
I shall not employ any person in any manner so as to become subject to the V N
ATER
Workers'Compensation laws of California. Date ` sTE3.4/TREATNc PAID
—
zZ Applicant NEW RESIDENTIAL IPLMB. SQIT. Date Recef t#
Z O NOTICE TO APPLICANT.If,after making this Cerliiate of ExempOagyou
should become subject to the Workers Compensation pt"teof the Labor TOTAL:
N Code,you must forthwith comply with such Tom or this rno"hallbe
2 — d pyP"' provisions Pe BUILDING FEE
W >, deemed revoked. N� _
mlvsrxurnoN LENDING AGENCY SEISMIC PGE GC/a�VQ•-
d Ihereby affirm that there Is a construction lendingagency for the performELECTRIC FEE
Z ante of the work for which this permit is Issued(Seec.3097,Civ.C.) TOTAL.
U O I.endera Name - - PLUMBING FEE Q
Lenders Address QTY. - MECHANICAL PERMITFMNID
FEE
Icentfythat]have read this applimon
tlonand statethat theabove Informati
O MECHANICAL FEE
WC Iscorrect.I.gm,to comply with all city and county ordinances and state laws 1 PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize mpresentatives of this
F W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify a d keep harmless the City of Cupertino Date Recei t#
O
against liabilities,Judgments,costs and expenses which may in any way aceme AIR HANDU NG UNIT DO 10,000 CFM) SUBTOTAL- '
against said
�City iim mery
�aence of the granting M this permit.
p�1,&2 "4/ p- 9��oleI AIR HAND vcUN rovE 10,000 CFM) CONSTRUCTION TAX
Signature of AppBant/Contncbr fl9`-CJ I Dcf EXHAUSTHOOD(W/D=) 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 t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
Health and SafetyCode Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Y. n No
Will the applicant or future building occupant use equipment or devicesVENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area AG ,
Quality Management District?- BOILER-COMP DHPOR IOQOW BTU)
4Ys ❑No
haveread the hazaraousmaterials requiremenbunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) a®
the Californiaat If ilh&Safety Code,Seccrrentl have 33and,that
understand that otify the occupant of t e currently iyments tenant,lust bcl met NEW RESIDENTIAL MEGH. SIj.I?.
priortoib uanc nalfy the occupant of
Ocl the requirements which musl6e met !�
prior to issuance of a Certificate o(Occvpanry. 7
l
Owner or authonaed agent Date ISSUED BY:
TOTAL:
OFFICE COPY