22817 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERMITNO. -
Building Add reae: 22817
'►o x--16 G
wnere ams: one: APPLICATION SUBMITTAL
CITY OF CUPERTINO-BUILDING DIVISION q
':`ntrumal Neme: Lic.No: ,APPLICATION / PERMIT
"J5 BUILDING-ELECTMCAI.PLUMBINGMECHAMCAL CATEGORY CONTROL#
rcM1iteR/Engineer. Lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: K Sc/ti/�iyf/ 7>ERh{ITISSUANCE r-00 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provtlons of Chapter 9 fixemmene, APPLIANCES-RESIDEN71AL JOB DESCRITT N
It... .1.fe Section 7000)aof nd afeion3ofthe Buslnessand lgrofesalaneCode,and my
Lice lain fuIf and Lie.R'
PANELS
Lice Cis Conte sot i2'z
Date Contractor IT IQ 211 AMPS
ARCHITECTS DECLARATION 201-[000 AMPS
az Iunderstandm law elanbe used as public records OVER1000AMPS
q YP P f $/SQ.FT.
q��uuOO J „ —
6i Licensed Pro(emloral SIGNS ELECTRICAL ( _
OWNER-BUILDER DECLARATION ,S SPECLILCIRCUIT/MISE O V T
zFQ 'b Ihereby afOrtexempt zempt(romlhe Contvctor'e License Law for the Y
OZ following reason(BeR1on 70X.5,Business and Profanation.Code:Any city or
county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.METER 0RPOLE[NST. i
any stmetere prior M its issuance,also requires the applicant for such permit to
ryL file a signed statement that he is licensed pursuant to the provisions of the ['OWER DEVICES DAI E
0� Contrad.e.License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING[VOL ELECTRIC
aion3 ofthe Busineaeand ProfemimuCodOmthat he texempt therefromand _ VALUATION
the basis for the alleged exemption. Any violation of Section 7071.5 by any -D I �•
applicant Turn permit subjedamore
the applicant to a civil penalty of not than OUTLETS5W[TCHFSF[%'IURES U D
five 1,as o nerdolof the pr. NEW RESIDENTIAL ELECTR SQ}7, STORES - TYPE CONSTRUCTION
QQQ �n M I,as owner of the property,or my employees with wages as thele sok
c le(Secamn,.
will Buss ethe work and the s C structure Intended or coffered for
sale(Sec.7061,Business and Professions Code;The Contracieh License Law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does suchwork himself or through hlsownemployees,providedthatsuch U
improvements,are not intended antlered for sale.l(however,lhebulldingor TOTAL: .U
improvement issold withinoneyearofcompletiogtheowner-bulWerwill have
t e"rden of proving that he did not build or improve for purpose of sale.).. (M. PLUMBING'PERMIT FEE FLODZONE APN
LJ L as,owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �U/n
contractors to construct the project(Sec.7044,Business and Professions Code: V
The Contraciore License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bullds ,
or Improves theme end who rontraRg for such japoins -
with a
re a&We)Ranged pursuant to the Contractor's License Law. FEE SUMMARY
RACK FLOW PROTECT.DEVICE
I am exempt under Sea B k P C for this reason
uei DRAINS.FLOOR ROOF,AREA,COND. - ' SANITARY Y N .
- Dale RECEIPT#
WORKMAN COMPENSATION DECLARATION pp(�(tES PER TRAP (� SC1100L TA% Y_ N%[21.h.ereby affirm that I have a certificate of consent to self4rearm,a a r RECEIPT#
bC.) rYsn'Compensationlruunna ora certified ropy themof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3X00,Lab CJ
. Policy a RECEIPT N '
Com any - GAS FA.SYSTEM-OVER 4(EA) - BUILDING DIVISION FEES
�Cedified copy is herebythMe city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rti(ied copy b tiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
Gm becom
COMPENSATION INSURANCE SEWFISAMTARYSTORM EA 200PT Date Recei t#
- (tR axRlon need notbecomplded](the permit t(orone hundred dollars
(81Io)aless3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y ."N
]certify that In the performance of the work(orwhkleer
h this permit is ed, Y_
,N_
shall not employ any person N any manner m as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
0 Z Applicant - NEW RESIDENTIAL PLMR. SQFT. Date Recei tilt
Z O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you
should become subject to the Workers'Compeasatlon provisions of the Labor TOTAL:
fD Cade,you mustforthwlth comply with such provtionsortht perMtahallbe BU G 'E .
deemed revoked.
.IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affirmthat there to mratmRion leadiagagency forthe perform TOTAL. 'q SEISMIC
FEE
7 r 0'
D Z anceofthe work for which this permit isissued(Sec.3097,Civ.C.) •UO
V O Lender.Name � PLUMBING FEE 1 -t Cd
LL F Lend.e.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W heti(ythaflhavereadthl appliatlonandrtatethattheabovelnformation '
IsarreR.Iagreetocomplywith act cityand countyordinancesand Rate laws PERMITISSUANCE FEES PAID:
} B• relatingtobuildingrowtrudion,and hereby authorae representatives of this
Fm N city to enter upon the above-mentioned property for impaction purposes, ALTER ORADDTO MECH.
Z (We)agree to gave,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against llabNtles,judgment,codeand ex nssswhich may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against Id Cityin corsequence oft ming of this perm .
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigm reof Applicant/Contract Date f EXHAUST HOOD(W/DUCT) CONSTRUCTIONTAX PAID:
HAZARDOUS hrATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei tM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the'
Health and Safety Code�+.-S�ection 25532(a)7 HEATING UNIT(OVER I00,000 BTU) 'TOTAL: . 06
I]Yes II No
Wlllthe applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) I$$U�A�N�CgDATE
wh I)cmit haraWous a4 contaminants as defined by the Bay Area Air PAID
aiity Mai lgement DisMR7 BOILER-COMP OEI'OR 100,000 BTU)
Yes nn No
have read the haza•Zoeuss materials requirement under Chapter 6.95 of 3011,11R-COMP(OVER 100,0(0 BTU) _ OCT
the California Heaithk Sa( Code,Sations 2550.5,25533 and 25534.1 MFS
understand that if the building does not currently have a heart,that it is my NEW RESIDENTIAL MECH. SQ.FT. '
mspomibility to notify the occupant of the requirements which must be mot
prior to Issuance of a Certificate of Occupancy. Of CUMUDD
Owner or authorised agent Date \
\ ' TOTAL: ISSUED BY:_
OFFICE COPY