22369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PERMIT NO.
Bu Id ing Address: 22369
996 i%v ash
nes ams: one: A A
T ��,� CITY OF CUPERTIN&BU1LDING DIVISION
t ;97— Lic.No: APPLICATION It PERMIT
IJ BUILDING-ELECTRICAT PLUMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lic.No:
r�3 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: trd 4(i PERMITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment APPLIANCFSRESIDENTIAL )OB DFSCRUPDON
ingwith Sectton7000)of Divisim3ofthe Busiusand PmtevonsCode,andm (� y�
license is In ful effect. PANELS Cis\- a� q_ 4 f- Q_
Licen Cl L1.1 .S�87215 LL7-1 fti
Date Contractor
ARCHITECTS DECLARATION 201-1000AMPS
rc Z I understand my platy shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
a d U Licensed Professional SIGNS ELECTRICAL p/�� 1III Tp''�
�C� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC //-�� 0�, "�.
L., (hereby affirm that l am exempt from the Contractor's License Law for the
ZO_3
following w... UWpMET[RORPOLEINSf. ` 6Ud P �'
OZt.y� countywhich requlresa permittocorutruct,alter,improve,demolish,orrepair
E F1
anystmmmpHortoiti antealwrcqubestheapperantforsuchper tto POWER DEVICES
file a signed statement that he t licensed pursuant to the provisions of the ! / Z
pOro� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DA eM
1il30 sion Sof the Business and Professions Code)orthat heleexempttherefromand
�.' the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHIS-FIXTURES I ,s�/r� (``�'J
O� apptcant for.permit subjects the applicant to a civil penalty of not more than L W�
five hundred dollars OSS, NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
Z ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is not Intended or offered for
psale(Sec.7044,Business and Professmru Code:The Contractors License Law
apse does net apply to an owner of property who Wilds or Improves themoo,and OCC GROIII' RIS.UNITSF- who does such work himself orthrough his own employees,provided that such
improvement are not Intended orolfered for sale.If,however,the W ilding or TOTAL:
Improvement b sold within one year ofcompletion,the owner-bullderwill have
th ;dere of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
I_I S as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coretruct the project(Sec.7044,Business and Professlore Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pRojxes with a FEE SUMMARY
.6p1I.cUs,O)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
. Owner - Date RECEIPT T
WORKMAN COMPENSATION DECLARATION FIXTURES. SCHOOL TAX Y_ N_
❑l hereby affirm that I have a certigate of consent to self-Inure,ora RECE a
ceaificate of Workers'Compereation huurarmora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPTX
Policy GAS F.A.SYSTEM-OVER 6(EA) BUILDING DI VISION FEE IS
r1
Com any
Cerlltled copy is hereby furnished. GRGSE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CD Certified ropy is filed with the city inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASE TRAY PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recd t#
(Thisseelon need not be completed if the permit t for one hundred dollars
($100)or ten.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 certifythat In the performance of the work for which this permit Is owed,
I shall not employ arty person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of C.aI fo-t. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQ.Fr Date Remi t#
Z O NOTICE TO APPLICANT.Ifafter making this Certificate of Exemption,you
should become subject to the Workers'Compensation provtiomo(the Labor TOTAL: _
W Code,you moat forthwith comply with such provisions orthts permit shall be BUILDING "E t
j deemed revoked. SEISMIC FBG
W — CONSTRUCTION LENDING AGENCY
ISO
IL I hembyaftirmthat there t a construction lendingagency forthe perform TOTAL: ELECTRIC FEE
M Z asw.(the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
() O Lender'.No
LL ~ lendces Address QTY. MECHANICAL PERMIT FEE MECHANICAL FGE
L) Icertifythat l have read this application and statethatthe above Information
O W Is correct.I agree to comply with a0 city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
�. (1 relating tobuilding construction,and hereby authorize representativesofthb
N ALTER OR ADD TO MECH.
1" Z city to ent upon the above-mentioned property for inspection purposes. Date Receipt#
(W a to save,Inde fy d harmless the City of Cupertino AIR HANDLING UNIT([010,000 CFM)
T ti P
O against 11 ilitles,7a � e s,c an x nsss which may In anywayaccwe SUBTOTAL:
agai Id City ro gaenr n ming of mi.Penni'
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S tare of App ret/Cont- or Dat EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDO SM .4/1 LS UISCLOSUA
Willtheapplicant orfuturebuild oceapant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
m serial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
lkath and Safety Codr Section 2553Ha)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: \s ]V
❑Yes �No VENILATION FAN(SINGLE RESIDE ISSUANCE DATE
Will the applicant orfuture building om+paN use the Ba Area
devices
which.Management airrict? ntas deRmd by the Bay Arca Au BOILER-COMP OFT'OR 100,000 BTR) JUL 4551�
_ Quality Management District? ps
Yrs FFo�No
4havemadtheth&a fet mater Sa tom255nt5533 and MM.
of BOILER-COMP(DVIRTOO,OW BID)
the costa rnia Heath k Ssfcty Code,SMlom 25505,255.3 and,Shat. I city
YI °upidno
understand that it the building docs no[arrcntly have atewnf that ttkmy NEW RESIDENTIAL MECH. SQ.FT AM Y MITI
wipmuibBity to notify the occupant of the requimment which most be met �\
prior to Issuance of a Ccrtl ficam of Occupancy.
Owner or authorised agent Date ISSUED 64\\`7"�• IC/"� �r
70TAL:
OFFICE COPY