22673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL-POINT PEN ONLY
buildingProject Identification PERMIT NO.
BuRd1 03 W ESTA�CS �� �. 22673
{'IyE(�ry W 1141U T 2 CITY OF CUPERTINO-BUILDING DIVISION
""Ker: MC CoMA-S Lte.No: APPLICATION I PERMIT
. BUILDINC, LI RICAL-ILUMBING-MECHAMCAL CATEGORY COZo
Architect/ neer. CAP
L4.No:
la OTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
1^
Address: /„q 1 fZA-h{,DjJ A IP V PERMITISSUANCE � ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prbvalonsof Chapler9(mmmao- APPLIANCE4RESIDEMTAL JOB DESCRIPTION
ingwithSection 7000)of Dlvislon3oftheBuslnemandPro(nslonsCode,and my
license ie In fuI(o and d(ect. I PANELS ACM,�a a, O
Icenx Chea LIc.Y 30 d i,J ,I,l`
14.0
ate Contractor `C ,QJUPTO 200 AMPS
ARCHITECTS DECLARATION 701-IOOOAMPS
.7 lundetstand myplarnshslbeused apubecremrds. OVERIWDAMIS SQ.FT.FLOOR AREA $/SQ.FT.
Llcenxd Professional - SIGNS ELECTRICAL , „ 1 -
OWNER-BUILDER DECLARATION
{,�'v, t
z F & Y SPECIALCItCU1T/M]SC
There's aform<hatlamexem fromsa Contractor's Code:Any Lawfarthe
poo (ollowing reason.l5ectlon 78115,Business and Pro(eauns Code:Any city or
FF'cy cmuntywhlchrequlmapermittommftcyalter,Impmvedemnlbh,or repair IEh1P.METER ORIOLE[NST.
33 aoystrocture pdorla Its issuance,alaorequlrntheappBuER nt(oreuch permit to POWER a algae i statement that he b licensed pursuant to the provisions of the / 2J
Ow1� Commodes License Law(Chapter 9(mmmencingwith Section 7DDD)ofDIA.
�OJ son 3oftha 1uslneuand Pro(dshm,Code).,that he bexempt there(romand SWIMMING POOL ELECTRIC LLUU
Q.•,£]] the bash for the alleged exemption. Any violation o!Section net m by any OUTLETSSWITCHESFIXTURESJim / J
applicant fees peaMted exemption.
applicantAny
vioation of penalty of net.5 by hanany
five hundred dollars(S500). NEW RISIDCNTIAL ULECTR SQ.ET. STORIES TYPE CONSTRUCTION
❑L as owner ofthe property,or my employees with wages as thelr,o4
7a mmpeneation,wllldothe work,andthestrocrom b not Intended or offered for
O sale(Sec.7a Business end Professions Code:The Contractors License Law
�$ does not apply to an owner of property who build,or improve thereon,and
who doem
suchworkhlmsel(orthugh hisuwnemployees,provided thatsuch OCC.CROUIP RFS.IINRS
Improverrcnb are not Intended oroffered forests.If,however,lhebuilding or TOTAL:
Improvement b sold within oneyearofcomplction,the owner-builderwill have
the burden of proving that he did not build or Improve for purpose ofsa4J. Cry. PLUMBING PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMHISSUANCE
contractors to coatruct the project(Sec 7076,Buslneu and Profesalons Code: Is
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improve thersan,sed who mMracta far such p�oprn with a
cgp((actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt order Sec B k P C for this..aOUTSIDE FEES
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
• Date
WORKMAN COMPENSATION DECLARATION RECEIPT Y
[31F)XIURES-PER TRAP L SCHOOLTA% Y N
1 hereby affirm that I have a certiBote of consent to self-Insure,or• RECEIPT Y
certiflcateofWorken'Compemationlmunnmoraredifledmpythereof(Sea GAS -1INC.i OUTLETS PARK FFE Y N
3800,Lab C.)
Polley Y //6 R '? ie RECEIPT Y
Com v fiyl�jtp yg '�-- GAS EA.SYBTEMOVER 4(EA) - BUILDING DIVISION FEES
Allied copy b herebyfurnished.Ihecit. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cedifled copy b filed with IM city Impectlon division.
CERTIFICATE OF FI(EMPTION FROM WORKERS' GREASE TRAP PAID {/��Y���
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA]00111. Date Recel [#`o
(I'hbeedlon need nut be completed](thrmi
e pet b for ane hundred tlll
oars ,
($100)or less.) WATER I IEATEt W/VENT/ELUCTR ENERGYFEE Y N
ce
I di(ythat In the performance ofthe work forwhich this permit's Issued, —
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
O Workers Compensation[.met CaEfornb. Data PAID
nt
Z 0 NOTICETO APPLICANT:ILafter making this CertBiotecu Exemption,you NEW RESIDENTIAL ELMS, SQFr. D 1 [#
1"
should become subjxt loth,Warken'Compensatlon provbkn o(the Labor TOT L:
V3 Code,you swat forthwith comply with such pmvblom orlhb permit shall be
LU > deemed revoked.
W C CONSTRUCTION LENDING AGENCY SE F E
d thereby affirm sU DING FEE
hat there lsematmction lending agency for the pedorrry
� Z ance of the work!or which thio permit b Wued(Sec.3097,Civ.C.) TOTAL. a ELE C ' (�
02 Lender's Name PLUMVNGFEE
Iy F Larder's Addroa QTY. MECHANICAL PERMIT FEE ME ANICAL FEE
OW Iurti(ythatl have read this epplcelionand statethat theabove lnfarmatlon
IL bmraM.lagrceto comply with ellctty and county ordinance and state larva PERMIT ISSUANCE FE' PAID,
>. W relating to building construction,and hereby authorize ropmxntaBvn ofthls
I— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
V _ (We)agree to save,Indemnify and keep harmless the City of Cupertino to Receipt#
against llabNtles,pdgmenb,costeand expenses which mayhenywayeocrus AIR HANDLING UNIT(rO 10,000 CFM) SUBTOTAL:
agxiat said City cane - encs of the granting of thio permit
/��>/Y AIR HANDLING IIMT(OVER 10,000CFM) CONSTR ON TAX
III tura of Appcant/Contractor Date EKHAusrHOOD(W/DUC"D CONSTRUCT NTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wilitheapplicant orfuturebulldingocmpantstomor handle hazardous HEATING UNIT(TO 100,000 BM
mateml as defined by the Cuperti no Municipal Code,Chapter 9.1 7,and the _ Date Recel
health and Safety Cade Section 25537(a)7 HEATING UNIT(OVER 100,000 BID) TA
❑Yee No
Will the applicant or drum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haurdous air conumlouru as defined by the Bay Area Air
Quality Management OlsMct7 BOILE&COMP OHPOR 100,000 BTU)
Yes n❑No ��p
havereacithehazat�'ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTLI)
the California Health A Safety Code,Sections 25505,25573 and 75536.I
uademand that if the building does not currently have a tenant,that it is my NEW RESt DPNHAL MECH. SQ.FT �C'r' 'i V pay
responsibility to notify the occupant of the requirements which mu at be and F JJ1
prior to Luuance of a Certlf4ale of Occupancy. ('�_„`/)
s
Owner or authorized agent Data ISSUED
TOTAL: - —
OFFICE COPY