22846 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification - - PERMIT NO.
Building Address: • • 2 2 8 4 6
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w AL DA 11
CITYOFCUPERTINO-BUILDING DIVISION ����� ryI
APPLICATION /PERMIT Q^ Z
HOLDING CATEGORY CONTROL X -
Architm/Engineer.
QTY ELECFRICPERMIT FEE BUILDING PERMIT-INFO
'Address; - PERMITISSUANCE - N4 ❑ E] 11LICENSED CONTRACTOR'S DECLARATION
with Se affirm ion7Othatlam Bcrosehe Busiroass daoffe aonsr9(mmmm APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Ssction7000)of Dlvlslon3ofNeBusin4-Code,and my s tL`�x '
B=B=
is in fu? effect. �J (� PANELS V[ f 1 Y••L�R_l�a i—�^'S.YF,y/�
k `— LICN D J
Date U' Contnctor
ARCHITECTS DECLARATION 201-1000 AMTS
q 2 ffw
I understand my plans shag be use as public mord& OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
° ` LED IN
k IJ Fj Licensed Professkwl, SIGNS ELECTRICAL -
�¢
OWNER-BUILDER DECLARATION SPECWLCIRCUIT/MISC p1 e p r ^
IMrcby affirm tOWNE exempt ER DE LARATION cense Law(w the r lT /a`rt K
)9/F.� following reaaon.(SMlon 7031 S,Businessantl Professions Code:Any dty or TFAIp.MET[R OR POLE INST.
u1 ewntywhich rcqulrsea permit reconstruct,alter,improve,demolish,ormpair tea/
5`•mO�Cai aeystructurc Intorno its Issuance,alsorequires theapplicant forsuch permit to POWER DEVICES DATE
e b
5 or file a signed statement that hIlcomed pursuant to the provisions of the
3°u. Contnnoes License law tChaprer 9(commencing With Section 7000)ofMvi-
�OQ slon3ofrhe Business and ProfesslonsCode)orthathetsexerepttherefromand SWPMhGIXOLELECWC VALUATION
oy in•-I ,the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7LE.fSSWLfCH6SF]XTUItFS
1d Oda
appticant fora permit subjectsthe applicant to a civil penalty of not morethan aO`+
five hundred dollars($500).I
1'9_' F1 I,as owner of the property,or my employees with wages as their sole NEV.'RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
�7a compensation,will doth,work andthe stricture b not Intended or offeredfor
O sale(Sec.7064 Bu it.res and Pmfesslons Code:The Contractofs License law
$ does not apply to an owner of property who builds or Improves thereon,and .00C.GROUI' RFS.UNITS
whodoessuchwerkhimse8orthmghhisownemploym provldedthatwch _
improvereentsarenot intended oroffered for sok.If,however,thebuilding w NOTAL: -
improvement isaold wlthinoneyearofcompletion,the owner-builderwill have
14,,Ilurden of proving that he did nor build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
"1,as owner of the property,am exclusively contracting with license - FLOOD TONE APN
contractors to mostruct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Imves re
protheon, and who contracts for such ptojece with a
cgngador(sI licensed pursuant to the Ctractor'sLicense Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
on
L�I am exempt under Sec. B'&P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
�. Owner Date RECEIPT0
WORKMAN COMPLTa5AT10N DECLARATION FXTUIRES PER TRAP SCHOOL TAX Y_ N_
ereby aHlrm that I have a mrtiflcate of consent MAT.
ora RECEIPT N
certificate ofWorloce Compersatlonlecurance on a certified ropy thereof(Sec.
3800,lois C.) CAS EA.SYSTEM-1 INCA 0UTLETS PARK FEE V_ NRECEI _
1'olkyY y DING DIVISION
Co�anv��� GAS FA. BUILDING OI VISION F[E5
Certified copy is herebyfumecity CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
�errtkd copy la(Ikd with the city Inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAIT PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. DdIC RCCCI I#
(This section need not be completed If the permit b for one hundred dollars
(s100)wleaa.) WATER I-IFATFRw/vFxr/FT.[CTR ENERGY FEE Y_ N_
I rectify that U the performance of the work forwhich this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workors'Corepensatlon Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT:If,after making this Cor�Hiate o(Esemption,you
should become subject to the Workeri Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthis permit shall be - BUILDINGFEE
W > deemed revoked.
CONSTRUCHON construction
DING AGENCY SEISMIC FEE
a.5 . Thereby offk for w there bacomtwcUon ld(Sec. agency 097,Civ.C.)
perform TOTAL: ELECTRIC FEE
7 Z once of the work for which this peter lsbwed(&c.3097,Civ.C.) '
02 I.ender'a Name PLUMBING FEE
F- I<nder'a Addrtss QTY. MECHANICAL PERMIT FEE
LL U IremfythatI avemadthbappti�tknaematethauneaWvemfomatien MECHANICAL FEE
0 W Iscorrect.l agreeto complywith all cityand countyordinanms and state laws PERMIT ISSUANCE FEES PAID:
�. G relating to building comtructlon,and Mrsbyauthome,representativesofthk - -
~ N cit to entero the above-mentioned for tra len ALTERORADDTOMECH.
Z y(we).gree o,ava maemnity an a locep Pct:mlea the iny or Ina - Date 'Receipt#
O agaimtlkbll es,Ndgmenta staand expenses which may in anyway accrue AIR HANDLING UNff(f010,000 CFM) SUBTOTAL:
agatnstsa icy in rood the anti of the.Permit. -
AIRHANDLINGUNIT(OVER IBUX)CRD CONSTRUCTION TAX
Igo reef Applicant/Contractor ate EXHAUSTHOOD(W/DUCT) CONSTRUCTIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheappilontwfuwmbuildingocmpantstomorMndlehan ous HFATINGUMTUO 100,000 BTI) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
11,.Ith and Safety Cade Seal 320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
0 Yea : ' o
Will the applicant!inure building occupant use equipment on devices VFNIIIAIIONFAN(SINGLERASID) ISSUANCE DATE
which emit hanedom air contaminants as define by the Bay Arca Air
• Quality Management District? OOILER-COMP(3F8'DR l00,fXq BTU) - ^
4Yea FZNW/ �Q
have readtheh. orruamaterabmquime nt•underChapter6.95of BOILER-COMP(OVER 10,000 BN)
the Glifernta Health&Safety Code,Sections 25505,25533 and 25534. I f• Ps a
understand the if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.17 OCI J 1,9.7r
msponslblllt onotllyth omrpant of the requirements which must be met -
priortoix nce ofd i(i fOc span _ p
Q /O/ _ {•tiQ
Owner or authorisd agent D/te-ry7/— TOTAL: ISSUED BY:
• - '
t OFFICE COPY