22346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PE MITNO.
Balding Address:IcYILL e O LE t)E B r oG 417 22346
ners ams: one;
l-I'e�4JLE,7T- %CkA" CITY OFCUPERTINO-BUILDING DIVISION / ��
Co muctoe..Name: Lie.No: APPLICATION I PERMIT l9
Ty'JV 5:' ('EGT721C t 7yb'37 BU(LDINGfl.ECTRICAI.PLUMBINGMECHAMCAL CATPGORY CONTROLIS
A¢hltM/[ingineer. Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. BLDG ELEQ1
PERMETISSUANCE rd ;X O E
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamlicensed Merprovisions olCo , APILIANCESRESIDENML JOB DESCRIPTION
ingwthSrdkn7000)o(Dvlpom3oftheBuenessandProleiedox.Cdoiind
my
Ilwnee la in too f. effect, PANELS �.
Limn C n Lk.N_ 1
Date Contnctor�f/p LEC, B'5....
ARCHITECTS DECLARATION 701-IODOAMPS
9
0 O I understand my plata shall be used as public records. IOVFR10DOAMPS SQ,Fr.FLOOR AREA 3/EQ.FT.
Licensed Profenlo'aI SIGNSELFGTRICAL LAS
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC Fig ED IN
7gt' following I hereby affirm than am exempt from the Contractor'&License Law for the ER
0 0 owing reason.(Section 7Business,Business and Profenlons Code:My city orCOW
� muntywhkhrequlresapermittommtmd,alter,lmprove,dem hsh,ormpair TEMP'METERDRPOLE INSf.
$� anystmcture prior to its bwance,also requireatheepplicant forsuch permit to
file s signed datement that he is licensed pursuant to the provbiav of the ROWER DEVICES
8 µ Contractor's License law(Chapter 9(commencng with ih S7000)of Dlvl-
O t`n SWIMMING POOL ELECTRIC
pon3 ofthegusinesa and Pro(emian Code)orthat he V eremptthercfromand
S the basin for the alleged exemption. Any ,violation of Section 70)15 by any q ODTLETSSWITCIIF_SHXTURBS
<� aPPllcantfora pemdt aubjech the applicanitoactWl pevlty of cant more(fun 3
five hundred dollars%500). NEW READENTIAL ELECTR
❑I,as owner of the pmperty,or my employees with wages as their sole �' ONSIRUCTION
7�< compcnsation,willdothewwk nb
andthestcturcwt intended or offered for
❑ elle(Sec.7616,Business and Pmfessloa Cade:The Contractor.Llwme Law
3� does not apply to an owner of property who builds or Improves there,Rand
whodansuchworkhimrelforth.ghhisownemplayee.,provldedthateuch •�
Improvements arc not Intended oroffered for sale.It,however,thebuilding o TOTAL: J•SO
improvement bold wlthln one yeam(completion,the owner-bu IW erwlll have
R)9*mc.of proving that he did not build or improve fee purpose of Is.). QTY. PLUMBING PERMIT FEE FIAOD ZONE APN
LJ L as owner of the pmperty,am exclusively contracting with license
contractors to construct the project(Sm 7061,Business and Professions Code: PFRMITISSUANCE
The Contractor's License Law dm nest apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improves thereon, and who contracts for such ptojecls with a
"g0trador(a)Licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sea B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
OUTSIDE FEES
Owner Date RECEIVE M
WORK MAN COMPENSATION DECLARATION FD(NRpg PER TRAP SC1100L TAX V N
❑I hereby affirorke that 1 have• lmarane of condi to opytheu f or a REC�,1
ortlflcate,(Workere Compevatlonl�tsurano:,ranrtl(kd copythercof(Sec. GAS EA SYSHM.1 INCA OUTLETS PARKFEE Y N
3800,Lab
Policy M G RECEIPT a
Comnnanv O 1 T. / GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FE ES
������ln .�F 19CA C J nF an ao IT
ZCertlfted copy V hemby th the cid. GREASE/1NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertllled copy V(fled with the city inspection divisors.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SAMfARY.SIORM FA.7WP1'. Date RCCCI t#
(fhlssMian need not 4 completed tithe permit V(Drone hundred dollars
(4100)orlen.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icartilyllnot thato the person
ofthe work so as t bthis subject
blued,
I shall no employ any person In any manner n n to become subject m the WATER SY517EM/TREATING
Workere'Compematlon lawn of California.Dae PAID '
O Z Applicant NEW RESIDENTIAL PLMB. Daft Remf 1#
Z O NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you SOFT•
Hshould becomesubject to the Workers'Camperaatlon provisions,(the Labor TOTAL:
N Code,you mast forthwith comply With such provisions or this permit shall be
j deemed revoked. BUILDING FEE
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm tk IsTOTAL:
hat there Is a construction lending agency forthe perform-
M O an.of the wwhich this permit ued(Sec.3097,Civ.C.) ELECTRIC FEE
ork(,'
0 _ lander.Name PLUMBING FEE
IL I— Lender'.Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtlfythat l have read thlsapphration and stalethatthe above ln(orrtation
IL L+mrrect.Isgreeto comply with all dtyand county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding mrutructlon,and herebyauthorom reprommative.ofthls
Z
city to enter upon the ab,vo-menlioned property for Inspection purposes, ALTERORADDTOMECH. Oa1C Reeel t#
V — e)agree to save,Indemnify an d keep harmless the City of Cup.Aln, p
gabut labllltles,jrdgments, sass x n hichmaylnanywayaccme AIR HANDLING UNIT(TO to,=CFM) SUBTOTAL:
against aid qty inc of a anti o enn/lt.
b 3 AIR HANDLING UNIT(OVER 10,000CpM) CONSTRUCTION TAX
Wire of Appuont/ ontractor Date EXITAuS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATE ALSDISCLEISURE
Will the applicant or future building occupantmore or handle hazardous (SEATING UNIT(TO 100,000 ME Date ReCCI t#
serial as dented by the Cupertino Municipal Code,Chapter 9.12 and the �_
I lealth.M Saety Code Sen1on 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ycs No
Will the applicant or Lure building occupant use equipment or devices VEND LATION PAN(SINGLE RESID) ISSUANCE DATE
rout Managernert altrict? minants a.defined by the Bay Arca Air
Quality Management District? BOILER-COMP PHPOR l00,0008TU1 �yr�,
4'Yea ❑No !f�'/—`E'/'I(�13L1
hawe read the bake ausnalerlals requirements under Chapter6.95 of 110MER-COMP LOVER 100,000 BN)
the 011f,mla Health&Safety Code,Sections 75505,25533 and 75536. I
understand that It the building does not currently have a tenant,that It is my NEW REMDENTIAL MECH. SQ.FT.
rmpoMlboityto not fly the occupant of the requirement s which moat be met l� a`�a7e (`avy
prior to exua me of a Certificate of Occupancy. C/Tar
OWnermauthortudagcm Date ISSUED BY:
TOTAL:
OFFICE COPY