22073 APPLICANT TO ILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_ Jqg BuildingPro'ed Identification PERMIT NO.
407?S " s
Bund Add /� ��. � � /!/�nl 22073
AppocATTORMITIUM—ere CU� {/f�,}�Y/ one: /fUPE /CJ A A
yny CITY OF CUPERTINO-BUILDING DIVISION , 1,
/"i are6�¢T�l/ 3y APPLICATION / PERMIT
BUTLDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL A
Architect/Engineer. Llc.No:
/ 7 QTY ELECTRICPERMIT FEE ' BUILDING PERMIT INFO
Address p 62
0a /�A 3, g�`G7�� ��� PERMIT ISSUANCE � ❑ ❑
I hereby. LICENSED CONTRACTOR'S DECLARATION
ffirm that l am Leensed under provisionsof Chapler9(cammenc, APPLIANCFSRMDENTIAL JOB DESCM-1 ION
Ingwith Secdon7000)ofDlvlslon3ofth BuM and Ppfasslons Code,andmy
LIca ieialnfull3o de((ect ]�!^ '.r PANELS � `�„a
License Claae LIc.A 7(((000a] c ?;?
SQ
Date Conmador UP TO 2EX)AhTS
ARCHITECTS DECLARATION 201-IOW AMPS
Fes+WZo lunderstand myplam.haled
beusaspubro
llcrerds OVERIDOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
E ob U Licensed Professional . SIGNS ELECTRICAL u
«<<Qw OWNER-BUILDER DECLARATION ISC
Iii] SPECIAL CIRCUIT/M
y'-' Thereby a(0rm that lamexempt(romthe Contractor's License law(m the
pp !allowing reason.(Section 7W 1.5,Business and Profession.Code:Any city or
O 2 F~ TEMP.METER OR POLE]NST.
r4 anystympriorlresapermittacaonquiasthemprovgdemsuch,orretto
W6
any stmcture statement
1.at he is licensed
pursuant to the Eor isimut of t e POWER DEVICES
6� 6 file a signed statement that M V Ilrenfed pursuant to the proxMlom o! the
3 w Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUA
O lion 3ofthe Buslnessand ProfenbraCode)orthat bele exempttherefromand T[O L TE f�
<� the basis for the alleged e.emptlon. Any violation of Section 70115 by any OUTLETS-SWITCHES-FIXTURES W
applicant fora permit subjects the applicant to a civil penalty of not more than
flno as owner of
NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRICTION
�m m I,as owner of the property,or my employees with wage as there dole
compensation,Will dothe work and the kumstructure not Intended or offered for
q sale(Sec.70Kpply to alnowand Profmbru Cobuilds Contraoves liceme law
doxes whodot applyloan owner ofproperty ereaghiswho
nemporlm,provided s thereon,
And OCC.GROUP RES.UNITS
whodocseuchworkhimself arthraugh Msownemptoyeea,provided that such ,
Improvementsarenot Intended craffered forule.ILhawever,thebuddinger TOTAL: L
Improvement issold withinoneyearofcomplelion,lhe owner-bullderwill have
tfli of proving that he did net build or Improve for purpose o(ule.). Qty. PLUMBING PERMIT FEE
LI FLOOD ZONE APN
L as owner t the property,cam exclusively Business
and
with Bremed PERMIT ISSUANCE The conCo arsct caLiven the project(Sec.appy Businees and Iof propertionsy
Cade:
Wil Contrayaro es the e.,Law does eat apply to an owner d property with
a ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon,and who mntnda ice such p ojecia wkh a
C7B((actorte)Iiceraed pursuant to the Contradals License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B&P C for this reasonOUTSIDE FL[S
DRAINS FLOOR,ROOF,AREA,CONED. SANITARY Y N
Owner Date FE) _ - RECFR'f A
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
�1 hereby affirm that I have a erti can of consent m sp(them,ora - R RECEIPT A
cert,LabCfWorken'Comperwtlonlmuranca on certified copy thereof(Esc. C FA.SYSTEM-1 INC.90UTLECS' PARK FEE Y N
38 W, # C.)
Try tl ( .. • . - I RECEIPT'N
c pA.sysreM_oSErsa'ieri II
BUILDING DIVISION FEES
45
!fled copy N
he famished. GRE
A 4N {JSfRLW "41P PLANCI-IECK FEE
Cenlied ropy b filed With the city inspection division.
CERTIFICATE OF EXEMiPEION FROM WORKERS' SE 11UP_ PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G 200FP Date Recei t#
(Thissenion need not be completed lithe permit b far one hundred dollars
(SIW)orlessd WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the perform mos of thework forwhich this permit is timed,
I shall not employ any person in any manner m as to became subject to the WATER SYSTEM/TREATING Workers Compensation Lawsof Callfomia.Date PAID
z ZNOTicant -
ICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ.ET. Date Recel t#
O should became subied to the Workers'Compensation provhlom of the Labor TOTAL:
CICN Code,you must(am hwith comply with such provisions or this permit shall be BUILDING a�
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
CL IhembyafOrm that there is a canatmdlon lending agency for the perform- ELECTRIC FEE l
Z anreofthe Work(orwhlchthbpermitLslssued(Sec.3097,CIv.C.) TOTAL:
U O 1<nder's Name PLUMBING FEE.
LL ~ Lender'.Addreas QTY. MECHANICAL PERMIT PEE- MECHANICAL FEE
OW Icertify lhatl have reacithiaapplicaft ..ed Matethatthe above information
1 brorrect.I agree to comply with all city and cauntyardhances and Mate law. PERMIT ISSUANCE FEES PAID:
} N relzlingto building camtmdion,andhe yawhor@empresentativesafthb •
Z cityloentW
mentlone perry(or irapActon purposes. ALTER OR ADD TO MECH. Da[C R2CC1 t#(We)omnlfy a ep harmless the City of Cupertinoagareatlla ,caps d penes wh mayinanywayacave AIR HANDLING UNIT RO 10,000CFM) SUBTOTAL:agairat .rare gra ting epennl�� /
/r AIRIiANDLING IIMT(OVFR IO,000CFM) CONSTRUCTION TAX
'Igmmre o(AppBcan/ nirador Date �/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardens HEATING UNIT CED 100,000 BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RY. n No
ill the applicantorfumre building occupant use Nulpereat or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardoes air contaminants as defined by the Bay Area Air
Quality Management District? - BOILER-COMP ORP OR 100,0110 BTU)
YeaNo
have read the hanuus materials requirements under Chapter 6.95 of BORER-COMP 100,000 BT U)
the California Health&Safety Code,Sed lora 25505,25533 and 25539.I
u aderstand that if the building does not currently have a tenant,that it is my NEW RES DFNIIAL MEG-[. SQ.FT. drys I
responsibility to notify the occupant of the requirements which moat be met • R t
prior to Issuance of a Certificate of Occupancy,
Owner or authorlud agent Data
TOTAL: ISSUED BY: J' �•• ul./a� �C9
OFFICE COPY'