22569 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B;d�3$o: HA4VCg J CT. 22569
s ante: / one: A A
rerA�/ t v 408`{ 30 CITY OF CUPERTINO�BUILDING DIVISION f4,
coet,atlor',Name: Lie.No: APPLICATION /PERMIT
Architect/Englnee. Lie.No: BUILDING-ELECTRICALnWBINGMECHANICAL CATEGORY CONTE C-:9,L
A�'� AA r c Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
J
Address: PFRMITISSUANCE
LICF.NSF.D CONTRACTOR'S DECLARATION
I hereby affirmthatlaiAsion3ofthe uMnemalonsof Chapter9eleand c- MPLIANCESRFSIDEMIAL JOB DESCRR'I'ION
Ingwith in full
to.
efelan3o(the BuAnessand Pro(eAdonsCode,and my
license bins !arae and c.N PANELS
License Class Lic.p �—
Date Contractor —UP IQ 2NAMRS
ARCHITECTS DECLARATION 201-1000AMPS
1Q+�aCZ Iunderstand my plans shall be used as public records. OVER 1000 AMPS SQ.FF.
FLOOR AREA $/S.FT.
E Z() Licensed Professional SIGNS ELECTRICAL
G w OWNER-BUILDER DECLARATION
In a FnSPECLlLCD2CUlT/MLSC
Thereby afOrm that lam exempt from the Contractor's License Law for the
gFQ following Mawn.(Soctlon 7071.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
3, cwntywhichreqursapermlttommtmct,alter,impmwdemolbh,ormpalr
anysim t mpdortoltsbsuance,ahorequlreatheapplimntforaochperMtto POWER DEVICES
gg a file a signed statement that he Is Brensed Pursuant to the provisions of the
Contractor's Licence lnwfChapter9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
F+�Og .lon3afthe Businessand ProtemlomCode)orthathebewmpttherefromandVALUATION
alleged exempAny violation the basis for the altion. Alation of Section 70315 by any �A .�1 pp'7
L/ OUTLETSSWITCIIFSF7XIURES . 13 L CJ 1 ( D
�O appliantfor a permit subjects civil m
the applicant to vil penalty not than I {
five hundred dollars S500). NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPECONSTRUC'TION
5 �n ❑I,as owner of the property,or my employees with wages as their sole z compensation,willdothe work and thestrucmre b not Intended or offered for
O
sale(Sec.7044,Business and Profession Code:The Contractors License Law
$ does not apply to an owner of property who builds or imprwcs thereon,and
$^ who does such work himseUor through his own employees,provided that suchOCGGROUP RFS.UMTS
Improvements are not intended or offered for sale.If,hmvevem the build Ing or TOTAL: {
pmvementlswldwithinoneyearofcompletion,theowner-b gderwllllove
t"non of proving that hedid not bulla or Improve for purpose ofsale.). Qn. PLUMBING PERMIT FEE FLOOD ZONE APN
L-J 4 a,owner of the property,am exclusively contracting with licensed PERMUISSUANCE
contactmrs to construct the project(Sec.7044,Business and Pm esslom Code:
The Contractors Llcerse Law does not apply to an owner a property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pt,ojeas ouch a FEE SUMMARY
co}0(actor(.)licensed pursuant to the Contractor's Llmnx Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reason
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX Y_ N_
F11 hereby affirm that I have a certificate of consent to self-Insure,ora FIX'IVRFS PER TRA)' \ RECEIPT I
certificate of Workers Compensation Insurance ora cenifid copy thereof(Sec. GAS E.A.SYSTEM-1 INCAOUTLLTS PARR FEE Y N
3800,Lab C.) —
PT
APolTryp GA EA. - VER C(FA�J r- r"� I ! DINGRECEDIVISION
any BUILDING DI VISION FE[S
ertlfied copy is hereby furnished. GREASE NDUSTRL WASTE INTERCEPTOR PIIANCHECIC FEE
Certified mpy b filed with the city inspection division.
�• i1
CERTIFICATE OF EMCREASE TRACERTIFICATEIXPTION FROM WORKERS' - /� PAIDL Z
COMPENSATION INSURANCE SEWER SANITARY-SICRM EA 200FT % Date Recel t# J
(Th6sedion need not d completed if the permit b for one hand and dollar _ - L—
($1W)orless.) WAI•ERHEATERW/VENT/ELECTR E E•RGY FEE Y_ N—
I me ify that I the performance of the work forwhich this permit Is heaved,
1 shall not employ any person In any manner so as to become subject to the WATER SYSITM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICETO APPLICANT:IL after muking this Certificate of Exemption,you
N should become aubjsct to the Workers'Compensation provlslom ofthe Labor TOTAL:
Code,you must forthwith comply with such provlslom or this permit shall be BUILDING " aL9J
W _ deemed rooked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE ,
CL Ihereby affirm that them b a construction lending agency for the performELEC
TOTAL:'
FEE Q
_
D Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) ' PLUMBING FEE
() O Leeder',Name
LL f I.rulee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ass
OW 1 cenifythat I have read this appbationand statethatthe above Information
S bcorrect.I agree to comply with all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID'.
). relating tobullding construction,and hereby authorize eeprexntativesofthis
J... N city to enter upon the abovo-mentloned property for Inspection Purposes. ALTERORADDTOMECH. \� s
Z (We)agree to save,Indemnlly an d keep harming the City of Cu Penton Date Receipt#
V age[car liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
aga mit said City in once of the granting of this permit.
� °'�`� AIR HANDWNG[ATT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signature AppBa actor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 10LOD08TU) Date ReeeJ t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
I lealth and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Ye. , MN.
Will thcapplicant or fumm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) L ISSUANCE DATE
which emit ha,arelous air mntamimrts as defined by the Bay Area Air
Quality Management Distrin] BOILER-COMP OIL'OR 100,000 BTI)
'n
Ycs �No
"('have read the hav ous materials requlrertenb under Chapter 5.95 of BOILEA-GDMP(DVI72100,000 OTU)
the California Healthi,Safety Code,Sections 75505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. PQ.FT \ee qr
responsibility to notify the cecvpanl of the requlmments which most be met V
prior to issuance of a Certificate of Occupancy.
Owneroraulhoriaed a gent Date
TOTAL: ISSUEDB •'ssc4Trr
OFFICE COPY