22404 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY .
Building Project Identification PERMIT NO.
Buing mas:---1 �lrnsct 22404
wn aName: Phone: APPLICA7T0177U8K117rAr=A
�>✓}(>;�}(1C �p� CITY OF CUPERTINO-BUILDING DIVISION
° r'9`Na ne: ^t - LpoNo' APPLICATION / PERMIT ®—ql
Avnrz \ O BUILDINGELEC7MCALML BINGMECHAMCAL CATEGORY CONTROL N
rchitetl/Englme Lk.No:
C.�.., QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
�YP—LUMb tom"
Address: 1 1 1� ,y —\Ya PERMITISSUANCE ❑ ❑ ElLICENSED CONTRACTOR'S DECLARATION I$
[hereby.
fflon,'bat l am licensed under provisions of Chapler9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing Mth Seccion7000)of DiAa.3ofthe Businessand PmfmlonsCode,and my
Li is lU f�-1 deflect. 1V`I 1��^(' PANELS �� J
Limn V CHYFE TSDECLAR N is tl ly
Date ContractorUP TO 2DOAM2S
ARCHITECPSDECLAR N201ER10 AMPS
aZ I understand my plans shall 4 used v public records OVER[BBB AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00
x z(/ Licensed Profesomal SIGNS ELECTRICAL L E D
OWNEReBUILDER DECLARATION P U T E R
'L., [hereby affirm that I am-BUIL ER the Contractor's License law(w the SPECIAL CIRCUIT/M15C
'� following reason.(Section 7Q115,Buslnm and Profmbns Code:An city or
5��� a Y pair POWER E VICES I,E[NST.
6) roun ing rea rcquimapermlttoromtmct,alter,bnprove, Code;Any
cit
anystructure lents ismheIs li mudl pursuant to the provisions
of permit POWER DEVICES
file a signed statement that he V r9(cum pursuant to the tion 70om of the fl
Divi-
lb <
Contractor'sLicenseLaw rodesser9(code)orthat
athalsng Section7000)omand SW�hINGPOOLELECTRIC
54 thebasflbe Businessand Profmlon. Any virlationoseection hercfromany VALUATION
4 J the liars for the permit
u exemption. Any ttolacon of natty o 70315 re any OU'ILE.ISSN1.fCFIESF]X'MiFS
�¢� five handredaollars subjectalheapplicant tea civil penalty of not more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR
I,as owner of the property, employees with wa es as their sole SQ.F. STORI6 TYPE CONSTRUCTION
�S^ P Perp,^P ^YB
compensation,will do he k and the structure 6 rwtl d or offered p sad(Sec.704Business and Professions Code:The Contractors License,Law
rag docs not apply to an owner of property who Wilds or improves tharem,and OCC.GROUP RFS.UNITS
who docs such work himselforthtough his own employees,provided that such
Improvements am not Intended oroffered forsale.If,however,the building or TOTAL:
Improvement bend within oneyearofcompletiogtheowner. uUderwgI have
OILIfurden of proving that he did not Wild or Improve for purpose ofsals.). QTY. PLUMBING PERMIT FEE FLOOD2ANE ApN
[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cmu,acton to construct the project(Sec.7044,Business and Profmlom Code:
The Conlractars Llmnse law does act apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon, and who contracts for such pwiects with a
cactcr(s)Bmnsed pursuant to the Contractors License Law. FEE SUMMARY
bgRllI am exempt under See. B 6 P C for this reason BACK FLOW PROTECT.DEVICE
— _QQTS I DE FEES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
�/ WORKMAN COMPENSATION DECLARATION RECEIPT M
.6iI hereby af(Irm that I have a certificate of consent to self-Imre,or a FIXIlIRES PER TRAP SCIBOOL fAX Y_ N_
certificate of Worken'Compnuation Insurance,ore mnified copy thereof[Sec. RECEIPT X
MOD,Lab C.) X�I I GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE RECEIPT N
Pollrytl _ GAS FA.SYSTEM-OVER4(FA)
Com anv BUILDING DIVISION FEES
Certified copy R hereby fumisha i. s
eriffled copy is filed with the city impeco..division. GREASE/INDUSTRL WASTE INTERCEPTOR ILANCHECKFEE
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR SAMTARY SIDRM EA 200FT Date Remi tlf
(Ihlamctlon need nm becompleted lithe permit b(orane hundred dollars
($1Icorf that
-ed, WATER HEATER W/VENT/ELECTR ENERGYFE'E Y N
[certifythatoy anyhe ersonI any munnehe k so as to bco permjecut ist to the —
I shall not employ any person In any manner ro m to become subject to the WATER SYSTEM/TREATING
workers'Compensation Laws of California.Date PAID
C• Z NOTICApplicaE NEW RESIDENTIAL PLMB. S,.FT. Date Remi t#
Z O NOTICE TO APPLICANT:](,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation proviai°m of the labor TOTAL:
�F N Code,you most forthwith comply withnuch provisiomorthb permit shall be BUILDING FEE
> deemed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirrnttat there V a construction lending agency for the perform- TOTAL: ELECTRIC FEE
u O Lceefthe work for which this permit La Issued(Sec.3097,Civ.CJ
V Le^dere Name PLUMBING FEB
Iy U L radar's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iwrttfy.It grlhaveread mply with
alkatyndcoonte that yordinancesetatelainformation l
umrmct.lagreeto<omply with alidtyand countyoNlnanms and nate laws PQtMRLSSLIANCE FEES PAID:
U) relating to building construction,and hereby authorize representatives ofthis
Zcity to enter upon the aWvcmmtmned property for impaction purposes. ALTER OR ADDTO MECH.
— (we)agree to save,indemnify an d keep harmless the City of Cupertino Date Re eipt#
against liabilities,jiodgments,costs and expenses which may In anyway2MMc AIR HANDLING UNIT CTO 10,ODO CFM) SUBTOTAL'
ag m aid City in coma a ofthe grantic ofthla permit.
^ AIR HANDLING UNIT OVER 10,000CFM) CONSTRUCTION TAX
inure of Apphcant/Contnnor Dae `f EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HATARDOUSMAT LSDISCLO UR
Will the applicant or future building occupanlatoeor Is hazwdom HEATING UNIT(TO 100,000 BTU) Date Recei tN
material as defines by the Cupertino Municipal Code,Chapter 9.1 2,and the
Iicallh and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
F-1YeaNo
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Marogemcat District? BOILER-COMP OHP OR 100,(X10 BTU)
Y.4 ave 4;°
have the bazar materials,deSat reoss 255ntsund and 25534.
of BOILER-CAMP rovp210O,000BM fta
unthe Califorerstandt Heath&Safety code,Senium255Q5,ve a tenant,that
1 JUL
understand that actifyf the the mgdoes nmcurrently have which thatb isot NEW RESIDENTIAL MEC}i. SQFT. .X
responsibilitytssua c of a Corti occupantofthe requirements which most be met d gA/se
prior lu issuance of a Certificate of Occupancy. oT7hLh�TA
Owner or authorized agent Data ISSUED BY:
TOTAL: i —
OFFICE COPY