22174 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
EjBulldin Pro 0(Welon Q ^ / PERtrRT NO.
B 'ng Address:
vis 22174 _
/ CI TY OF CUPERTINO-BUILDING DIVISION �` �RTMIM-
era o
L APPLICATION /PERMIT
BUILDING-ELECTRICAL-PLUMBING-MFCliAMCAL CATEGORY CONTROL p
Architect/Engineer. - Lie No:
Qrr ELfiCTRIC PE6INTF ^'FEE` :": BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ 0
r� .LICENSED CONTRACTOR'S DECLARATION
Thereby affUm that l am licensed under Pmvi»tors»o/Chapter I(commene- APPLIANCE.SRESIDENTIAL JOBDRSCRUMON
'mg with Ssdlon 7 W 0)of Dlvislon 3 c licensed
B uei nese and Profe�plen s Code,and eny
license le In effect. .PANUS
License Lie.p___ ( ls�
Date Contractor /N�
ARCHITECTS Ai 201-10D0 AMPS
?_ U
Tun erste myplaosshaBbeusedaspubhererords OVERIOOOAMPS $/SQ.Fr.
Licensed Professional SIGNSELECTRICALUTER
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISCI hereby affirenthat I am exemptfromthe Contractor's License law for the ^wTC �Iollowing reason.(SMlon 7031 S,Businessand Profeasbns Code:Any dty or vfg 11i `coon whichrc Iresa mit reconstruct,alter,Im v demolish,erre air TEMP.METER ORPOLE INST.b 9u Per pro e• P anyatmcturetatemettshathe I.abensed rersuant to thei rovisins of toPOWER DEVICES Ole a signed statement that he b licensed puauanl to the provlslOrct of the�.�.r Contractors License Law(Chapter 9(commencing with Sedon 7000)of Divi- SWIMMINGPOOL ELECTRIC
sion3 of the gestures and Professions Code)or that he is exempt therefromand VALUATION
the bads for the alleged exemption.Any violation of Section 7031.5 by any 0[ITLETSSWI7CHESFIXT[RES
applicant for a permit subject;the applicant to a dvil penalty of net morethan
five hundred delta.($500). -
I,as owner of the property,or my employees with wages as thele sole NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
compereabon,wilidothe work and thestructure is not Intended or offeredfor
❑ Is(Sec.70K Busineae and Professions Code:Th=Contractors License Law
does not apply to an owner of property who beilds or improves thereon,and ,OCC.GROUP RFS UNITS
C (y� who does suchwork himself or through his own employees,provided that such
v Improvements are not Intended or offend fee sale.If,however,the building or TOTAL:
Improvement Issold within one yearof completion,the owner-builderwill have
p� 0)9jvrden of proving that he did not build or Improve for purpose of sale.). QTY, z;' PLUMBING PERMIT "FEE pLOOD ZONE APN
lV\ Lf L as owner of the property,am exclusively contracting with licensed PFRMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contactors User se Lew does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
�y� builds or improves thereoM and who contracts.for such pSojeM with a i,•:
11�N,.J <q➢t�adar(s)licensed pursuant to the Contrador'e License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY:"
LJ I am exempt under Sec. B k P C for this reason -
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Omer Dare _ RECEQ''Tp
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCI1001,TAX Y . N
❑[hereby a((Irm that I have a certlOnie of consent to ani(-Inwre,or RECCE p
certitirate ofW ricers Compevatlonlruurance ora ce�(fled rop thppp���rrrof(Sec.
i,Lab GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
PolJ r' /�
PoBcyp REC GAS EA,SYSTEM-OVER 4(EA) [p
Co�any BUILDDINGING Of VISION FE ES '
reified copy b hereby furnished. CREASE/IIJDUSIEL WASTE INTERCEPTOR PLANCIIECK PEE
ertlfied copy is filed with the city nspectlon o .
CERTIFICATE OF MEMPTION FROM WORKERS' - GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date "Remi t#
(this section neetl net becompleted lithe permit b(Drone hundred dollars
($lW)mhoss.) WATER HEATER W/VENT/ELECTR - ENERGY FEE Y. N
ce
Irttfythat in the Performance ofthe work for which this permit is issued, - —
I shall not employ any person In any manner so w to become subject to the WATTR SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z NOT[AppliCamt NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICEiOMI'LTCANT:$after rs'Co pe cation pro is Exemption,you '
Code,you bocoenv�=at
;forth it the Work ere'such prwNonproWions s per it s Labbe TOTAL:
CC Ln Codreedumuat/otlhwith comply with such provisions or this permit shall be BUILDING •E
deemed revoked.
CL p comsrgucnoN LENDING ACDvcY SEISMIC FEE
I hereby affirm that there b a construction lending agenry for the perfornry . ELECTRIC FEE
Z amen of the work for which this permit b batted(Sec.3097,Civ.Q TOTAL:
U O Landers N. PLUMBING FEE
LL I- LandersAddreaa . - •Q7Y.,"' MECHANICAL PE2tvIITi� FEE: MECHANICAL FEE
0.W Icertllythatl have read thbappBratbnand statethatthe above information •
a brormet.I agree to comply with all cityand momyordlnancesdndstate laws PFRMITISSUANCE ( /r, •EES PAID:
} N relating to building construction,and hereby aulhorlu rcprexn[atives of this -
z city to enter upon the above Inep
-mentioned property for ecNon purposes. ALTERORADDTOMECH.. 0 Date Receipt#
— agree to save,Ind fy.an d keep harmless the City of Cupertino -
at labllitiea,judgme e, sande enaeswhich mayln anymyaceme AIR HANDLING UNIT 9010,0(0 CFM) SUBTOTAL:
age i s d Cp In cons of the tinting thle permit
47
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signature.( t/ n Dat ( IXHAusr Hoop by/DUCT).' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA WS RE '
Wllltheappllcantorfuturebu lwYvg r andleh..rclma HFATINGUMT(TO100,000BTU) Date Recei t#
material as defined bythe Cupertino Municipal Code, o pter9.1Zand Ne -
health and Safety Code Section-25532(s)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes 1�1 No "
Will the applicant or future building occupant use equlpment or devices VFNIILATION 14AN(SINGLE MID) ISSUANCE DATE
s which emit hararelous air contaminants as defined by the Bay Area Air 'll-1�
Quail,
..agement District? - BOILER-COMP OHP OR 100,000 BTU)
Ih , reaAh.. s terials requirements under Chapter 6.95 of BOILER-COMP(OVER100,OW BTU)
the I rolaode,Sed Dna 25505,25533 and 255M.1unde ndtoes not rrently have atenan4 that iii my NEW RESIDENTIAL MECH. SQ.FT.
ibllitsyantrequire nb which must b t pitrl
Owner or authotlred agent Date - - TOTAL: ,..?n ISSUEDB .
tt--CC.//
OFFICE COPY