22284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
eullding Address
IL [J�_�`-q ` 22284
�J one:
AppticATMMI CITY OF CUPERTINO-BUILDING DIVISION ter ^ A A
cont .Nam : Lie.No: APPLICATION I PERMIT l r
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
Arch ect/Enginee Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE
VO
LICENSED CONTRACTOR'S DECLARATION LL7
withS a(flrtnthatlamsion3ftheBuprovisions
andP fChmsCocommec APPOANCESRESIDENffAL ]08 DESC
ON
Ingwlthifull70W)ofd effeon3a(theBu,Inesandlsmfe,sionsCode,and my �� ! {O --
limnu is In lull( and elfM. PANELS
Llan Chs _ Lie.a_�S 5d �!�/ Q
Date CantnRor 5 CA
ARCHITECI'S DECLARATION 201-IMOAMPS
q�+ez understand my plans shall W used as public remds. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
a Licensed Professional SIGNS ELECTRICAL /' ^S � .Z
e �6c. that
lam GILDER DECLARATION . IAL CIRCUIT/MISC wR q W
7f' ,La owinghereby
Mon. thatlamexempt fromthe d Protrusions Code:
law(m the a, Ve.
op following reason.(Section 7031.5,Business and Profession,Code:Any city or
FZk'� cnuntywhlrh requbeapermittororetrun,alter,Mprovemo
,delish,orrcpait lr TEMP.MITERORPOLE INST.
L 1 B
y �Q anystmcture proem its issuance,aiso requlrestheappecant for such permit to Ii7WF.R DEVICES
file a signed statement that he is Ilmnsed pursuant to the provisions of the
Contractors License Law(Clupter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
don3ofthe Businessand PeofesionoCodOmthat he b exempttherefromand VA A'�p;C�
�'•.-fit the boob for the alleged exemption. Any violation of Section 70315 any
�❑
applicant fora permit the applicant to a civil nal of not more than UTLETSSWITCHESFlXTURES
PP permi kers PP penalty
five hundred dollen(S5'30).
?fin ❑1,as owner of the Property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
C < mptnsation,wiildo the work,and thesttucture is not Intended or offered for
j ❑ Sale(Sec.70q.Bus=s and Professions Code:The Contractors License law
�jsr$ does not apply to an owner of property who Wilds or improve thereon,and
who does such work himself or through his own employees,provided that Such OCC.GROUP RES.UNITS
Improvements am not intended oroffered forsale.If,howevegthebulldingor IOTA O
Improvement bsold withinoneyearafeempietiogthe owner-budderwill have I
ttla.tlunden of proving that he did rwt Wild or Improve for purpose of Sale.). QTY. PLUMBING PERMIT FEE FT-OO ZODN APN
Lj 4 as owner of the property,am exclusively contracting with licensed
contractors tomn5truct the project(Se.7044,Businesand Profesbru Code: PERMIT ISSUANCE
The Contnttor§License law doe eat apply to an owner of Property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or Improves thereuM and who contracts for Such ptojens with a
centfaetor(s)licensed pursuant to the Contrattors License Law. gAQC FLOW pR07'FGI DEVICE FEE SUMMARY
LI I am exempt under See. B 6 P C for thin reason
OUTSIDE F
Owner Dace DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
WORKMAN COMPENSATION DECLARATION RECFIPI N
❑I he
affirm that I have a certificate of consent to self4rdirs or FLXTURF_S PER TRAP , dOOL TAX Y N
certificate of Workeri Comperudtion Insuranceora certified copy thereof(Sec. RECEIPT M
S
3800,Lab C.) GAEA.SYSTEM-t INCA OUTLETS PARK FEE Y N
Policy 8 RECEIPT a
Com any GAS EA.SYSTEM-OVER4(EA) BUILDINGDIVISIONFRES
[]Cenlhed copy is herebyfamished.the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑CertNed copy h filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE /']_
Rhlasmion need not becomPleted lithe permit ta(oronehundred dollars SEWER-SANp
ffARY-STORM EA. pFT Date RCCCI t# ' -� L
($11 cerilyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I llnor that o the person
mnu of line work Sa as to become
penult h ho the —
I shall not employ any Peru.In any manner ao s to become subject to the
Workers Compensation Laws of Calllomla.Date WATER SYSTEM/TREATING PAID
O z Applicant
Z O NOTICETOAPPLICANT:If,eftermakingthis Ceetflnteoflaemptkm'you NEN'RESIDENTIAL PLMB. SQ.FT. Date RCtt't t#
F` Should become Subject to the Workers'Comperuatlon provislmu of the Labor TOTAL: 4
WN Code,you must fon hwith comply with such provisions or this permit shall be
> deemed mucked. ;BUIDING FEECL CONSTRUCTION LENDING AGENCY FEE
herebyaNrmthat there hacaM ucion lendingagency forthe performz once of the workfor Which this permit is lsvaed(See.3097,Civ.C.) IOTA ` FEE
O lenderiName G FEELL 0 I.enaer,Aadre,a QTY. MECHANICAL PERMIT FEEW Icon ify that l have mad this.pplicaeonend State that theabove information CAL FEE
is correct.l agree to comply with all city and county ordtranm and State laws PERMIT ISSUANCE D:
} N relating to building commctled,a.d hereby authorize representatives of this —C i
z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
(W)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
".Imt 1!4ilitles,judgments,cogs and expenses which may In any way accrue AIR HANDLING UNIT(TO]O,00(CFM) SUBTOTAL:
gaiyy adCity In conStgy� (theXrg of thea penni��
a/ 7e AIR HANDLING UNIT(OVER IO,000 CIM) CONSTRUCTION TAX
Slgnatumof Applicant/uontractorDate EXHAUST HOOD(W/DLCT) CONSTRUCTION TAX PA ID:
HAZ RDOUSMATERIALSDISCLOSURE fI
Willtheapplimtor(wt building—pantstorecrlundlehaza ., HEATING UNIT CM ILU,ODO BTU)
numnal.,definedby the Cupertino Municipal Coda Chapter 9.17,and the Date Recei t#
f leahh and Safety Cade Section 25532(a)7
❑ Yes HEATING UNIT(OVER 1 W,000 BTU)
Will the appliont ob No TOTAL:
r futum buildingoccup.dt use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminant,as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0W BTU)
4 Yes Ir I No
havereadlhehazar set mord S'lio,255nbunderChapter8.95 of HOILER-COMP t00,000BTU)
the Calllomh Health&Safety Code,Secilom 25505,7:,533 and 75134.I
understand that lithe building does not currently have atenant,that it B my NEW RESIDFNIIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be min ��
prior to iss ce
uan &a Certificate of Occup.nry. 4 "`M+
Owner or authorized agent Date �
TOTAL: a4-d/ ISSUED BY:
OFFICE COPY