22800 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
ru0ding Address: TZOO O
8 L4/
%,0.uars
amt: one: (,(
Ani-004n No 11 as7-Sl173 CITY OF CUPERTINO-BUILDING DIVISION
C°ntanor'aNamc Lm.No: APPLICATION /PERMIT
OH tf/ !Ow sY7 3 / BUILDINC-ELECTRICAL-PLUMBINC-MECHA#CAL CATEGORY CONTROL#
AreMtect/Enginee,. Llc.No:
S4—C 4, e6a. BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Add. PMMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hth SMio 7Ore Uut Dimi,lensed 3.fthder usirosaions ndPmfe aonsCodeanenc APPLIANCES-RESIDENTIAL JOB DESCRQ}7ON
Ingwlth5ca(on7000)of Dlvislon3ofthe Businnsand ProfeasloneCodeend my �.t ESC O `
license VIE(uE f and effect PANELS 1 V�/W
Limns Cla Lic.#
Date Contractor
ARCHITECT`S DECLARATION 201-IWO AMTS
0Zp lundcrstand my plain dull be used as public records OVER 1000 AMPS L LrL)OR 1`N F/SQ.FT.
HLirensed Profemleml SIGNS ELECTRICAL UU N
6 OWNER-BNLDER DECLARATION P T E R
I"n SPECIAL CIRCNT/M15C
ZF, Ihercbyaf(Irmthatlam exempt from the Contractor's License Law for the aM
fo0owing reason.(Sectlan 7mlS,Business and Profenbn.Code:Any tlty or
O rutrTfT4'.METER OR POLE INST.
P I-' rountywhlcA requbesapermittocouct,alter,improv4 demolish,orrepMETER
anystmu mpriwtoits uanceiisomquimatheapplimntforsuchper tto
file a signed statement that he is licensed pursuant to the pmvlslom of the POOR DEVICES
3 u.� Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
SOS slon3 ofthe Bugemand ProfessloreCode)orthat hats exempt therefromand
the basis for the alleged exemption. Any violation of Section 70115 by any OITILETSSWITCHES IXTURFS /�
appilant for a permltsubjeod the applicant to a civil penalty of not rorethan r, O 660
five hundred dollars%500), NEW RESIDENTIAL ELECTR
C]1,as owner of the property,or my employers with wages es their sole c"Q'ET' STORIES TYPE CONSTRUCTION
.compensation,will do the work,and the.Wclure Is not intended or offered for
Osale(Sec.7044,B..N and Profemiom Code:TAe Contractor.Limme law
$ does not apply to an owner of property who builds or improves thereon,and CCC.GROUP RES 1INHS
whodoessuch work himself orthrough hisown employees,provided that such
bnprovementa are not Intended oroffertd ferule.IL however,thebulldingor TOTAL:
improvementissoldwithnoneyearo(comple ioNtheowner-bu0derwlllhave
Ihee*rden of proving that he did not build or improve for purpose elude.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APR
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corutmct the project(Sec.7044,Business and Professions Code:
The Contactor'.License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bunds or Improves thereon,and who contain for such ptojecb with a
cgBVactw(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L.j I am exempt under Sec B&P C for this reason
DRAINS FLUOR,ROOF,AREA,COND. SANITARY Y N
OUTSIDE FEES
Owner Date RFCEBxT It
WORKMAN COMPENSATIONDECLARATIONSPER TRAP SCHOOL TAX Y_ N_
[]I hereby affirm that I hes a certificate of consent to self-Insure,m a RECEIPT#
drtl(imteo(Warken'Compereadunlnsura.cad.cartifled copy therm!(Sec. GAS EA.SYSTEM-1 INCd OUTLETS PARK FEE Y N
3800,lab C.)
Pdky# GAS EA.SYSV4(E1) RECEIPT 0
Com any I'Q.IAFR BUILDING DIVISION FENS
�Certlfled copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the cityIrupectlon division.
CERTIFICATE OF UEMPEION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA 200FT Date Recti t#
(This seniors need not be completed tithe permit is for one hundred dollars
($100)orlam.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I certify that In the performance ofthe work for which this permit le Issued, —
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workcrs'Compenutlon laws of California. Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Rech t#
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
Hshould became subject to the Workers''Compematlon provisions of the Labor TOTAL:
fA
Code,you=at forthwith comply with such provisions orthis permit shall he JLM
NG
FEE
W 9 deamed revoked.
0 CONSTRUC ION LENDING AGENCY SEISMIC FEE
IL
I hereby afflrnthzt there ts a ocrotruction lending agency for the perfomv TOTAL: ELECTRIC FEE
Z anceaftheworkforwhicN1LVamm to issuepp(Secs 309],CIv.C.)
(� O Lender.Name //O Le ad•� PLUMBING FEE
U. F I.c.d.es Address QTY.i MECHANICAL PERMIT FEE
O W luAifythatlhavemadthisapplimtlonand.tatethattheaboveinformmion MECHANICAL FEC
a Iscomed.l agree to conplywlth all city and county ordinances and state law, PERMPTISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives of this
Zcity to enter upon the above�nxrtlomd property for inspection purposes, ALTERORADDTOMECH. Date Receipt#
(We)agree to save,iMm
eNd
fy an keep harmless the City of Cupertino
V agaWtiisbllit dgments,rope and expenses which may inany way amus AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
ag_a/wj/�}Id ylri ne soft grantht'dthl.permi6 ATR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
24/32+--, CONSTRUCTION TAX PAID:
HAZA
Signatum of Appinor Date E%E1AIIST HOOD @V/DUCT)
AZARDOUS MATERIALS DISCLOSURE
Will ia the applicant the
rebuildingocevpan Code,
Cor hapter to 9.1
.h ad
HEATING UMT(TO 300,000BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety CodSection 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yee No
Will the applicant orfutum building occupant use equipment or devices VENTTLATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management fistrin2 'BOILFR-COMP OFR'OR 100,000 BTU)
4 Yea pQ No
have read lfiefi r smateriab requirements under Chapter&95 of BOILER-COMP(OVER 100,000 BTU)
the California I lealth&Safety Code,Sections 25505,25533 and 25534. 1 Cp
understand that If the building does not currently have a tenant,that It is 5 my NEW RESIDENTIAL MECH. SQ.FC ser z r' q9�^dp
rdponslblllty to really the occupant of the requirements which most be met f Y r
prions uan eo 02df test Occupancy, of
Owner or authoriA9 agent Dote ISSUED BY: *!^� "�'
TOTAL:
OFFICE COPY
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