22469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building Project Identification (�1 . 1 PFRMITNO.
BulWing Opd�ms♦r. _ ' /q ���! rvV - 22469
wnnerers me: one: �1�\►•, A
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P CITY OF CUPERTINO-BUILDING DIVISION
c°nba r " : Lie.No: APPLICATION / PERMIT
RIELDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY Cor
Architect/Engineer. Lk:.Na l99
'7
QTY' .ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERM YTISSUANCE w x/,
LICENSED CONTRACTOR'S DECLARATION L�J
j 'I hereby affirm that lam Bcenaod under provisions o(Chapter9(commenc APPLIANCESRESIDENTIAL JOB DFS�-0���/
Ingwlth S,01..7000).fDivi,io.3.fthA Buslnnasand PrefessimsCude,and my - ����jjVV��..//
1 limns,Is In full force and c.A PANELS P 6�
b License Clam Contr " 3
Date -CHITECe
ARCHITECT'S DECLARATION 0 AMPS
µo!O ZO I understand my plata slug be usedss public records OVER OVER 11000 AMT'S 5Q.Ff.FLOOR AREA S/sQ.FT.
E Licensed Professional - SIGNS ELECTRICALrr '
GGGG 6 OWNER-BUILDER DECLARATION
fn
Ihercbyafflrrbthatfamexem)Rfromthe Contrador'c Llanae law for the SPECIALCIRCUIT/MISC '
rR_Q qQ following reason, ectlon 7031.5,Business and Professions Code:Any city or
c° untywhlchrequlsSreaipert tWo =trod,alter, pmve,demolbh,orrepalr TEMP'MEfOt OR TOLE INST.
�� Q anystmdum prior to its imuamgalso requires theapplIcant forsuch permit to POWER DEVICES
r V file a signed statement that he h Ikenwd pursuant to the provisions of.the -
3 w�' Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.
O S MBNG POOL ELECLRIC :VALUATION
RIsion3ofthe Buelneaeefid ProfesslomCode)orthel hehexempt therclromand - - -
_ the bash foi the alleged exemption. Any violation of Section 70'11.5 by an E7SSWITCHESFlXTURES � � ''
applicant for a permit subjects the applicant to a civil penalty of not ore the
live hundreddollarsof he%pr). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION'
❑I,asownerof theproperty,or1u emturn Is with wage's theles ole
6 ro[AC3.. 0KB.slon hework,andthesCocturchnet Intended License
ed for
Law7IN&
��
❑. ale(Sec.apply
Bu siness and ProfessionsCod,:The or improves License Law does not apply to en ownerofpropertywhobuildsorlmprovesthercon,and �� OCC.GROUP RFS.UNITS'
who doessuchworkMmself orlhrwgh hlsown employees,provided th o' chImprovementsarenotIntendedproffered(mule.ILhowever,thebulldingor
Improvement isold withinoneyearofcompletion,the owner-buIliterwill havettae,-purden of proving that he didean build or Improve for Purpose fine.). QTY, MIT FEELJ L as owner of the property,am exclusively contracting with Ilmnsed FT.00D'lONE, APN
contractors to rorutmet the project(Sec.70K Business and Professions Code:The Contractor's License law does nor apply to an owner of property whobuilds orAmproves thereon, and who contrae,for such projects with a' ER(EA)
ontJ'actods)Bcensed pursuant to the Contracto/s License Law. BACK FLOW I'ROT[CT.DEVICE FEE SUMMARY _
LJ I am exempt under Sec B& re
P C for this awd - OUTSIDE FEES
Owner Date DRAINS.F(AOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION - - RFGm4p
❑1 hereby Wen that I have a-dificate oonce
f concent to self4ex.re,ora FIXTURES PER TRAP ,�,r. SCHOOL TAX Y_ N_
certifidmo(Workeescompo at nlnsura soramrti0edcopythereof(5ec. RECEIPT#
3800,Lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Poll , RECFITT p
CAS EA.,SYSIEM-0VER4(EA) BUILDING DIVISION FEES
Cert dcopy h hereby furnl CREASE/INDVSIRL WASTE INTERCEPTOR PLANCI'IECK FEE
Ce ed ropy is filed with the city Inspection division. ^T `CK 1a� Q[�yn�
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE TRAP-' PAID I1T1l v2`Ott
COMPENSATION INSURANCE SEWER,SAMTARY-STORM EA:200FT. Date RCceI (Il
O'hI..cfim need fid be eomplemd lithe permit later hundred dollars
(5100)orlem.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll not artifyemploythat In any person
In any mancerheweck An an to cern Permit Ito theed, `�
I shag not.Nr any LAson In any manner at u to become subject to the WATER SYSTEM/TREATING (�.
Workers Compensation Laws of Callfornh, Date PAID
Z Z Applicant ` NEW RESIDCNTTAL PLMB. SQ.FT. Date Recei SIN
Z O NOTICE TO APPLICANT.If,after making Fish E,rtlflcate of Exemption,you
Fshould become subject to the Workers'Compematlon provisions of the Labor _ TOCC TAL:
0 Code,you=at fort hwith comply with such provisions or this permit shall be BUILDING E
W j deemed revoked. -
a c CONSTRUCTION LENDING AGENCY. SEISMIC FL•E
1 hereby affirm that them la a construction lending agency for the perform ELECTRIC FEE,
Z anceof the work mrwhiclethh permit hhsued(Sec,3097,Civ.C.) - T
O O Lender's Name ' PLUMBING FEE 16
U. F Lender'.AddmmQTY. MECHANICAL PERMIT FEE . MECHANICAL FEB
OW Icertltythatl have read Fish epplMatlonaM state that theabove Information 1 ��
1 hcorrect.I agree to comply with all city and county ordinances and Male laws PERMITISSUANCE L FEES PAID:
r treating to bulldingmnstruatlon,and hereby aum
thorbireprentatives ofthis
N
r Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify and keep hpmeess the City of Cupertino - - Date RCCCIFf(I
V agalmtllabllI ,judgments, ander ensehvhlchmaylnanywayacwe AIR HANDLING UNIT(TO 10,000CPM) SUBTOTAL:
agai ai 1 in aarye fthe otingefthls permit.
P AIR]ttNDUNc osier(OVER IB,000cr•M) CONSTRUCTION TAX
5 cat f App leant/Contractor Date EXHAUSTHOOD(W/DICE 2 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
the a ppito ntor fuNre building occupant store or handle hazardous EIEA7ING UMT(i'0100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Rc ei
Health and Safety Code Section 75533(a)7 HIATING UNIT(OVER 100,000 BTU) T L.
❑Yes [j No
Will the applicant or future building occupant use equipment or devices VEMILATION FAN(SINGLE RESIU) ISSUANCE DATE
whicti emit hazardous air contamleants as defined by the Bay Area Air
Quality Mamg.ment DisWd7 BOILER-COMP WIPOR 100,000 BTU)
4Yes. ❑❑No p
have mad the hazarsl."a materials requirement.under Chapter G95 of BOILER-COMP(OVER 100,000 BTU) Y v
the California Health&Safety Code,Sed ions 25505,2W3 and 25534.I
u ndersta fid that if the he llding docs not of dordly have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT Asi9
a O
exapommo
ibllity to notify occupant of the requirements which at be rest nIV
prior to hee sux nof a Certificate of Occupancy. \ I' '
T�Owner or authorlad agent Date - SSUGD BY: %rvu
TAl
OFFICE COPY