22434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project Identification - PERMITNO.
Building Address; 22434
wnrs sets: one:
to CITY OP CUPERTINO-BUILDING DIVISION p
Conh•ctor• • ua•No; APPLICATION I PERMIT
• QLCS� APPLICATION
CATFfARY CONTROLN
Archl[eci/Engineer: Lk:.No;
OTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCEEl ❑
LICENSED CONTRACTOR'S DECLARATION D 19
I hereby affirm that l am hemsed under provisions of Chapter9(commene, APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwllh Section7000)of DlAslon3 ofthe Buslnessand Professions Code,and my
linnet b In full torn and i,.N C&
y� PANELS Fl(,--CT
License Clan Glb Co Y--_�E(GG/ �a[. Fl CT 1 �-LY-
Date 7—/h'C/ Contactor
ARCHITECT'S DECLARATION 207-1000 AMPS
qq��uu ot0 O L understand my place shelf co
be used n public rerda. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
ti Z Licensed Professional SIGNS ELECTRICAL m Contractors („ ® N
�QQ6 OWNER-BOLDER DECLARATION 3 gPEC1ALCIRCIIIT/MLSC N
F, 3 Ihereby.m.that lamexempt frothe Coractors License Law for the
qo following reason.(Section 70715,Business �i and Profeelons Code:Any city or P
!" countywhlchrequlmapemd w..M d,alter,bnprove,demnlbh,ormpalr TEMP.METER OR POLE INST.
anynrocture prbrroib tseua Me,atso requlrolheapp0ant farsuch permitto POWER DEVICES TE C
U file a signed statement that he la hnneed pursuant to the provision of the
Contractors License Law(Chapter9(commencing with Section 7000)of DIA- SWIMMING POOL ELECTRICse
S sion 3ofthe Businceaand Pmlenlmu Ced0orthm he tsexempt therefromand VALUATION
< the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESFTX'TURES
O applicant Lure permit subjectalheappllcanttoe civil penityoln
not rtrethan
five hundred dollars(g500). NEW RESIDENTIAL ELECTRSQ.FT, STORIES TYPECONSTRUCTION
�n ❑1,a•owner of the property,or my employees with wages as their sole
compensation,will do the work and the simcturt Is acct Intended or offered for
qale(Sec 70K Business and Professions Code:The Contradoes License law
does not apply to an owner of property who Wilde or improves therroR and
m who donsuch work himself or through We own employers,provided that such OCC.GROIIP RES.UNITS
Improvements are net Intended or offered for We.If,however,the Wilding or TOTAL: �Qp
lmimn,=nttssokl within onyeam(completion,the owner-W ilderwlll have
tIF-4uden of proving that he did not bu8d orlmprove for purponofele.). QM PLUMBING PERMIT FEE
FLOOD
L J OD ZONE APN
4 as owner construct
the property,am exclusively Business
and Pro with licensed PERMIT ISSUANCE
contacrorstocoLicense
ewdoe(Sec 70pl to
and Professions property who
The Contractor'improve"
e"the Law dad era apply tct an owner of property who ALTER-DRAIN VENT-WATER(PA)
Wilda t Improves thertoM and who contracts !o such p. with a
�gp([act.exempt under ant Sm
the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
EES
LJ I am exempt under Sec B 4 P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Dale RECEIPT tl
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
❑I hereby offirorke that I have o lmumn of a consent to pytheun,or a RECEIPT N
ce00,Lee ofWorkeri Campenatlanlnunnnorannlfkd copythereof(Sec. GAS EA.SYSTEM.1 NCA OUTLETS PARK FEE Y N_
38(10,Iab C.7
Com Ny GAS E.A.SYSTEM-OVER4(EA) B UILDNCD VISION FEES
Certified copy is herebyth the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCeditled copy ts flied with the city 1Mpectldn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.20017. Date Recei t#
IThia section need nothe<omploted If to permit la for enc hundred dollen
($100)mless3 WATER HEATER W/PENT/ELECTR - ENERGY FEE Y N
I certify that In the performance of the work farwhlch thio pemnit le blued, —
I shall not employ any person In any manner so an to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California,Date PAID
O Z Applicant - NEWRESIDENTIALPLMB._SQ.FT. Date Recel t#
Z Q NOTICE TO APPLICANT.If,aRer making this Certificate of Exemption,
you
Hshould become subject to the Workers'Compensation provision of the Labor TOTAL:
W Code,you must forthwith comply with ouch provision orthla permits hall be BUILDING
LU 7 deemed revoked. - FEE
.1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Thereby affirm that there la a construction lending agency for the perform- TOTAL: ELECTRIC FEE
7 assn oftheworkforwhichthbperrnitismued(Ssc.3B97,CIv.C.)
(� O Lenders Name PLUMBING FEE
LL F Lender's Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Indilythall have readthla applicationend statethal theaWvelnfomutlon
1 iscorrect.l agrestocomplywith all cityand countyordlnancosand olatelows PERMIT ISSUANCE FEES PAID:
} O relating tobullding censtmetlon,and hereby authorize representatives of this
F Z city to enter upon the above,mentionad property fn inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino Date Reeei t#
against lubilities,judgments,nate and expense•which may In any way accrue AIR HANDLING UNIT Q010,000 CFM) SUBTOTAL: . 0
agalMtsald Cityl eon mquenecofthe it gofthlepermlt ATR HANDLING UNIT(OVER IO,000CIM) CONSTRUCTION TAX
7—//�L
Signtureof Applianl/Conhactar, Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantorfuture building occupant store or handle hazardous HFATINGUNIT(11JI00,000 BTU) -
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the Date Recei t#
Health and SafetyCadySeVlon 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 0
Yno
Illlhe applicant orfumm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISaRe.wY.1Y1SnATE
which emit hazardous air contaminants as defined by the Bay Area Air -Y'RY�"
lity Management E�i,tr tt7 BOILER-COMP DHPOR 100,000 BTU)
4 Yes IvJ No
have read the hazer ms motorists requirement•underChapter 6,95 of BOILER-COMP(OVER 100,000 BTU) 1
the California Health&Safety Code,Sectlone 25505,25533 and 2:534.1
understand that if the Wilding don no currently have a tenant,that it N my NEW RESIDENTIAL MECH. SQ.FT. ��
reeponibllity to notify the occupant of the requirement,which most be mel ow Im
prior to Issuance of a Certificate of Ompancy.
- Ownerorauthoriaed agent Dale ISSUED BY:V ' —UC Li
TOTAL:
OFFICE COPY