22053 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES — US'E BALL POINT PEN ONLY
PET NO.
BulldinR Pr.mn Id.Identification RMI, 2 2 0 5 3 -
Budding Addresr.
Gr00 a��1 a
AVV1A.A 11UNS IoAil 1A6 UA 1C
CITY OF CUPERTINO-BUILDING DIVISION
s. Contrado/s Name: Lic.N. APPLICATION I PERMIT
BUILDING-p,ECTRICALPLUMBING-MFGFiAMCAL CATEGORY CONTROI Ile J.
—1^1'l
rchlted/Engineer. Lie.Non. L /
1�. I ,"t BUILDING ,tRMITINFO"'
ELECTRIePERMIT,,'� ' f1��„FEE'S '
Address PERMITISSUANCE 1 "•I� ��/�j'T
LICENSED CONTRACTOR'S DECLARATION
a p APPL1ANCRSRESIDENTIAL I OB DESCRIPTION
thereby affmetht A(commenc-I
,
Ingwith Section 7000).!Dvl.m.3ofthe RUalnesaand Profeeslon.Code,and mY Asa ,
license Is In full force and effect. - PANLIA
License Claa• -LIc.11 S ,
Date Contractor I �-
ARCHITECTSDECLARATION OV PS I SQ.FC.FLOOR AAFA S/SQ.Ff.
aO 7' I understand my pl.,Ix.9 be used as public records. j {'�
q�v O 9GNS ELECTRICAL
Licensed Profemloral -
q q CG°7 OWNER-BUILDER DECLARATION' !li C L CIRCUITAUSC
a Ihemby affirm that am exempt from the Contractor'.License law for the
QO � f omvmgmasen.(Sedion70315,B..I.and Professions Code:Mydtyor TEMP.N=( IR POLE INST.
F` countywhich requlrcsa permit to construct,alter,improve,dem.lbh,orrepair 1
`a nystrucure prlorto its lsauance,alsomqumsitheappliant(.Mauch permit to POWER DEVICES +I
file•signed atatemmt that he Is licensed pursuant to the pmvsiom of it
Contractors Llceme Law(ChaptM9(oMMx cingwith Sectkm7000)of Dtvi- SWIMNUNG POOL ELECTRIC VALUATION
30 slon3ofthe Business and Prof.niov C.de)ortha[hebexempithemfmmand 1
6 S the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES FIXTU L 1.RES s Co l ics,Q j
applicant fora permit eub)ecta the applicant to a civil penalty of nct oeretiO
five hundred dolbn(SSM. NEW RESIDENTIAL ELECTR__SW7 STORIES TYPECONSTRUCT'ION
M 1,as owner of the property,or my employees with wages as their WE-
Zt open.Hon,wBldothawork.odthestructum Exomiumoded or offered for ��q—p�@-
❑ sale(Sec.7)a4 Bwtneas and Profeul.ra Cody.The COntractors Llcerae law ■ ■ N V �\
f�r3$ doeanotapplyto an owner of property who ballds.r improves thereon;and - -- EIS.I1MfS -
'c�"" whodoeamchworkhVm iforthroughhtaownemployees,pravidedthatmi:. r
Improvements arc not Intended oroffered forests.](however the building or yy�
Improvement bold within oneyearofcompletion,the owner-bullderwill have .. �CT.��-,(�r��.�
the enofpmWngthat he didnotbu5ldorlmpdvx s for purpose.(as — (QTY,' PLUMBINCP / 1VE APN
L a owner of the pro perty,am exclusively contracting with licensed PERMITISSUANCE Aw
Pg
Ira to construct the projed(Sec.7094,Bwlneu and Profemlom Code: DA "T
e Cr om is License law doca not apply to an owner d property who ALTER-DRAIN&VENT-WATER
Wilde M Impray..thereon, and who contracts for so i'h p(okds with a -- ;r ' ! FEE SUMMARY' '
ado,(.)Banse d p unuanttothe CMuseor'.Lk.nse Law. I BACK FLOW PROTECT.DEVICE
m t I+P
LEI am exept under Sea B&P C for this reason {{11uT" FFS I
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner •lot. RFCEM 0
I) WORKMAN COMPENSATION DECLARATION FIXTURES-MTRAF SCITOOCTAX Y_ N_
^QI hereby affirm that I have.certificate of Consent to felf-Irmo,or a I RECEIPT N
cedmlloteofWorkera Compensation Laurance or a certified copythereof(Ser,l GAS EA.SYSTEM-1 INCL ownErs IPARKFEE Y_ N_
3900,lab C.) I RECEIPT N_
Policy CAS EA.SYSrM.OVER 4(SA)
C[ore�Cenv s BUCIK L C C DIVISIONFEC
erafied copy b hereby famihed. CREASE/INDUSTRL WAT INTERCEPTOR PLANCHE l
'
�L9., f❑Ccrtulm copy is riled with the city cope H.o dNl.t.n.
-/ CERTIFICATE OF EXT-MpT10N FROM WORKERS' CREASETRAP ' PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM EA.200FT. Date Reccipt
(fhbsectionneed out becomplel BtMpron t boron.hundred do)l.n '
(51 W)or7essJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N-
I certify that In the performance of the work forwhich this permit is Issued,
1.EaB not employ any person In any manner so as in become subject to the WATER SYSTPdf/TREATING PAID
W ak.ry Compensation Law.of CxIAMr..Date
0 Z Applian� NEW RESIDENTIAL PLMB.,_SQFT. Dale Refxlpt#
Z 0 NOTICE APPLICANT:If,after making this Certificate of Exemption,you TOTAL:
N abould become subject to the Walker'CompervaHon provisions of the Labor
_ Code,you must fort hwith comply with such provisions or this permit.hall bei ttBUILDING FEE / l�rx'
2 deemed revoked. 1 SEISMIC FEE f
(L CONSTRUCTION LENDING AGENCY
d 0 !hereby effirmthat there ba ronstrudlon lending agency for the perform, TOTAL: ELECTRIC FEE
D Z arm of the work for which this permit Is Issued(Sec.3097,Civ.C.) (PLUMBING FEE
02 Lendef.Nzn
U. 1- Iender'.Addmee U. MECHANICAL PERMIT 'I- - FE8'`AMECHANICAL FEE tG7J
w
is turned. l have read thhappliatIon and gate that theabove Information
O �Z OO�FEES PAID:
orned.I agree to comply withal)city and county ordinances and Mate law.( PERMtTISSUANCE
a relator to build In construction,a od hereby suihorlen representatives of this �p
F- N 'i toenteru on the above- ALTWORADDTOMECH, y,Cv Date Recel t#
Z city p mentioned property for at t Inspection purposes. P
(ost)agreeto save,
dgmeoemnits anexpepe.which may In way AIR HANDLING UNIT(TO 10,000 CFM)
V' ago WtllablBtles,pdgm.nte,costs expenses whkh may In anyway accrue SUBTOTAL:
gaga.iim/!tj_j�lddd CC,�ay l of the granting this permit. .� MR HANDLING UNIT(OVER 10,000 CFkU I CONSTRUCTION TAX
�(ltethre of Appuant/com Date EXHAUSTHOOD(W/DUCT) (CONSTRUCTION TAX PAID:
/ HAZARDOUS MATERIALS DISCLOSURE F1F.ATING UNIT 10),000 BTU
Will the applicant or Eaton,bu llding occupant store or ha nd Is haeandous _ I Date Receipt#
/ material as defined by the Cupertino Munldp.I Code,Chapter 9.17,and the
Health and Safety Cod a�+-S�ection 25537(a)7 HEATING UMT(OVER IOO,W38TN TOTAL: / ' jtt-��
Will MN. VENTILATION FAN(SINGLE RESIDE. ISSUANCE DATE
Will the applicant or forum building occupant use equipment or devices
which emir haeardous air contaminants ae deRm.•d by the Bay Ana Atr BORER-COMP(31 IF OR 100,000 BTO '
Qu ality Management District? .
4Yes ❑No . •
1awe read the hazallow matcrlaMaterials requimmenh under Chapter 695 of BOILER-COMP(OV9t 100,003 BTU) —ef
the California I Iealth&Safety Code,Sections 7550.5,25573 and 7553N.1 p` p
understand that lithe building does net currently haveatenani,that ltIsmy NEW RESIDENTIAL METH. ' SQ.Ff /� � J U
responsibility to notify the occupant of the requirements which must be met •\' �
pnor to Isom nee of a Cerhhcate of Occupa ncy.
Owneror authoner i agent Date TOTAL: k(„�,a w �ISSUEUB
OFFICE COPY