22514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Identification • ' r PERMIT NO.
NuBding Addrea �,E►-, , na . . 22514
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oars ams: AFFLICALIONSUBMIIIALD-Alr-
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CITY OF CUPERTINO-BUILDING DIVISION 7 q
cuno-aetnra Name: Lle.W. -S APPLICATION I PERMIT — 0 [
PyN T BUILDING¢ECTRICAL¢UMBING-MECHAMCAL CATFGbRY CONTROL*6614-/ /
Architect/Engines, 'Lk.No: (O(O
'BUILATNG PERMIT INFO
QTY t_•,ELE .TIZICPERIOITT .:FSE
Address: PERMITISSUANCE ❑ ❑ ❑
t LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provisions of Chapter9(commove. APPLIANCFSRESIDENTIAL JOB DE IUPTION
ingwith5 dion7000)oMvision3ofthe BuRne.and Professions Code,and my
license is 1Jan fuRf�f�cc and died. PANELS �,p ',r
Liren-&X_ Lic.p 3 ( D \L---�D VL
Dale Contractor UP O2DOAMPS000 AMPS
ARCHall be used
Epublic TION OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
. ; Al
nt0 O I understand r^Y plan shall be used as public records.
Licensed Profe.lonsl SICNSELECTRICA
Jy
OWNER-BUILDER DECLARATION
o I hereby affirm that l am exempt fromthe Contractor's License Law fee the
SPECLILCB2CUIT/
2 following reason.(Section 7031S,Business and Professions Code:Any cityor qp ST
countywhich requires a permltto construct,alter,improve,dm
eallsh,or repair
,3 anystmu mprlortoitsbmance,alwmquimstheappliuntforsuchperMtto pO D C
Ufile a signed statement that he is licensed pursuant to the provisions of the
O eco Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi- SIM I' VALUATION O
F30 smn3o(lhe Business and ProfeaonsCode)orthat he isexem thenefeemand
q the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETSSWI f I0 L9 D D
L`2'EE&55 9 applicant for a permit subjedsthe applicant to a civil penalty ofnotmorethan -
��` five hundred dollars($500). NEWg TO FS TYPE CONSTRUCTION
FlI,as owner of the property,or my employees with wages as their sole
c mpensation,willdothe work ancithestructure fano[intended or offered for DATE
Osale(Sec.7044,Business and Professions Code:The Contactors License Law
does not apply to an owner of property who builds or improves thereon,and - CROUP RES.UNITS
who does such work himself orthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL:
improvement bsold Mthinoneyearofcompldlorytheowner-bu0derwBlhave .
th,a�rurden of proving that he did not build or Improve for purpose of sale). QTY. ` PLUMBING PERMIT "'FEE FLOODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to mnstrvd the project(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wills or Improves thereon,and who contracts -
cts for such proje is with a •tFEB'•SC11�fMHE.ARY
cgLtrador(s)licensed pursuant to the Contractor's License Law. gACK FLOW PROTECT.DEVICE
L�I am exempt under Sec re
B&P C for this ason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N-
. Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
QI hereby affirm that I have a certificate of consent to pythemof ora RECEIPT Is
3800,Laeo(Workeis'Compensatlonlnsurance ora certl(led mpythereof(&c. GAS EA.SYSTEM-t INCA OUTLETS PARK FEE Y N
3800,lab CJ RECEIPT N
Policy p GAS EA.SYSTEM-0VER 6(EA)
Com any - BUILDING DIVISION FF.E$
Certified copy is herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b flied with the city Inspection division. �{ S�b
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASETRAP PAID 7•'�O�CL 6�
COMPENSATION INSURANCE SEWER-SAMTARY-STORM FA,2001F. L-7Date ReCel tN
(Thlssection need not be completed if the permit isfor one hundred dollars
($100)or 1e.') WATER HEATER w/vI:NT/¢ECTR - ENERGY FEE Y N
I corifythat in the performance of thework forwhlch this permit is based, -
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
WorkeriCompensation Lam ofCalifornia.Date PAI
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. h;_
1 [
Z O NOTICETO APPLICANT:If,after making this Cariiute of Exemption,you
should becomesubjed to the WorkersComperuaHon provisions of the LaborOTA :
� y Code,you must forthwith comply with such provisions or thh permit shall be L 1 Gx 1 , 00
W > deemed revoked. !
CONSTRUCTION LENDING AGENCY SEISMIC FEE (7
CL Iherebyafffrm that there b a construction lending agency for the perform ELECTRICFEE
M Z ac..fthe work(or which this permit is issued(Sec.3097,Civ.C.) TOTAL:
O O Lender's Name PLUMBING FEE
LL I— Lender's Address QTY:. MECHANICAL-PE ffiIFF; `t PEE''" MECHANICAL FEE
OW I certifythatl have readthls application and gate thattheaboveinformatlon
1 iscorrocL I agreeto comply with all city and county ordinances and Rate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this -
H city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
2 (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reaei tN
V against liabilities,judgments,cousand expenses which may in anywayaccrue AIR HANDLING UNIT GO 10,000 CFM) SUBTO AL:
agaimteaidC I'Laquence of the granting of this permit. AIR HANDLING DMT(DVER]0,000CFM) CONSTRUCTION TAX
{ CONSTRUCTION TAX PAID:
Sig ture (Applicant/ ontrador Date EXHAUST Howfty/DUCT)
HAZARDOUS MATERIALS DISCLOSURE '
Winthe applicant or tuturebuilding occupant smreorhandle hazardous HEATING UNIT 100,000 BTU) Date Recel t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER IW,"BTU) TOTA
❑ Yes ,I+�-,I No
Wllltheappllunt or turabOlding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) . ISSUANCE DATE
which emit haardous air contaminants as defined by the Bay Area Air
Qua lily Management D❑lsMd7 BOILER-COMP QHP OR 100,000 BTU)
I Yes rd No
Yen
erthe Fara Sus afety
Code,Se requirements;25533 and 25534.
of BOILER-COMP(OVER 1fA,000 BTU)
the Californiala atIftHealth&Safety Code,Sections25505,h,ve a tenant,and 75534.Iunders
respne ed olity to nthfy the ongdoes not a requirmentahicmost
tb is my NEW RESIDENTIAL MECH. SQ.Ff.
rnsponslbllltymndifytheompantoftherequirementswhichmustbemet1�8 'az ?S
prior to issuance of a Certificate of Occupancy. :1 M ,
i
Owneroraulhoriud agent Data ISSUED
TOTAL:
OFFICE COPY