22849 9PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PF3LMITN'O,
Building Address: 22849
A;�Sv�rcrP
Uwnerary /_ �� none. AI'1'WCAIIUN Itl\flit)}L DAIL
' - 'S'!'/.�JL CITY OF CUPERTINO-BUILDING DIVISION
contraaor'a Name: Lic.Na APPLICATION / PERMIT
BUILDINGS.ECTWCALPLUMBINGMECHANICAL CATEGORY CONTROL
Architect/Engneee Lic.No:
ItQ7i ,.•`.�{..,i.2c ELECTRICPERMTC,''�'. .1IFEEt, "':iB�BUILDING-PERMITINFO
Address ouw r�-n�t rL�mn .tri.n i
' PERMIT ISSUANCE
LICENSED CONTRACTOR'S pr DECLARATION sj�j.�J�
/hereby aft lint that lamlicensed anderprovbianaaf Chapter (rommme-I APPLIANCES-RESIDENTIAL I J( BDFSCAPIION
mgwith Semon7000)of Divsion3o(the Businmand Professions Cade,and my IIO Pet }n
bcenselain(uBmrmandef(eR. PANELS �(/�^r7-\ `L-
Date Class Lie N ` I
Date Contnttor S?'T22BP.°6m'e S
ARCHITECTS DECLARATION 201-I000AMI5 I I
q�+aiz I understand my plans Shan be used aa public meads i OVERIMOAMPS 7 f` ! Ii SQ.FT.FLOOR AREA $/SQ.FT. i
R d O Licensed Professional SIGNS ELECTRICAL !1 ^ '
6 OWNER-BUILDER DECLARATION SPKIALCIRCUIT/M1SC 1 _-� �J
t.., 3 1hembyaflrmthat l am exempt(menthe Contractor's License Lawtathe I w
(allowing mason.(SecHOn 70315,Business and Professions Code:Any city,or d '
0 o TEMP.METER OR POLE INST.
7s /
�O�•"� county requtma permit tocorolmfibe.the applicant pmve fors tch,armito Ts.a
, 5< any.fracture prmeronahauaMgaLcaredparrehebeporukins.f permit to )y3Wp-R DEVICES
^� I❑�7 O Ilse a signed statement that he b licensed pursuant to the proWlam of the
❑�u,!`n Contractors License Law(Chapler9(co.ricing with Semon 700))of Div)- SWIMMING POOL ELECTRIC I
doA3 of the Business and Pro(mlonsCode)orthat he is exempt therefromand __ --YdCUATION
the basis for the alleged exemption. Any Violation of Section 70315 by any C OUTLETSSWITC}{FSFIXTIIRFS
�5 X36'4 appllcantfsra permit subjects the applicant to a civil penalty data enrethm J ��t
E as dollar(5500). NEW RESIDENTIAL ELECTR SQFT.
.z. as owner of the property,ar my empWyen with wage as thetr se 1 STORIES TYPE CONSTRUCTION
pensation,wW do the work,and thestrumare Is not Intended or offered for
F O le Isec,70K Busine s and Profeesloru Code:The Contractors License La t
does not apply tow owner d property who Wilds or improvn thereae,and
wfiodocasuchworkhimulf orthrwgh hisawnemplgeea,provided thatsuch s _ +� OCC.GROUI' RES.UNIT'S
4np=ossi a arc not Intended mattered for safe.If,hawevemthe Wlldiogar TOT [([71_]7_
Improvement 9wld wlthoomrarofcompldoN theowner-bullderwillhave
this rden of proving that he did not Wild or improve for purpose ofsale3. Qi'Y, i., iS'PhS7MBING•PERMIT.'t'•: ., :)7:-FEE-I t FLOOD ZONE APN
L J L as owner of the property,am exclusively mntramng with lice PERMIT ISSUANCE IL
contractors to constmctthe project(See 704y Business and Protessaoms Cod e: '
The Comes or's License Law don r a apply to an owner of property who ALTER-DRAW&VENT-WATER(EA) _
Wilda or imponme thueon, and who contracts for such projects with a i"� .yy,''+s�' )r�
q�Tinttor(O licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE I I rF-, ,FEE.SUMMARY44tU,., I
cL.J I am exempt under Sec B&P C for this maven ' 1 �1s, -gnrcgtc FFI
• Owner Date I�a DRAINS FLOOR ROOF,AREA,COND. f1 / L / XANI7ARY Y N=
WOR KMA,N'COMPENSATION DECLARATION I Fp7ygps) .pgA)S I ISCHOOLTAX Y N
❑I hereby afRrm that I have a certificate of consent to self-inure,or a RECEIPT
N
comflcateofWorkers Compensation lesunncoora certified copy thereof(Sce.I GAS EA.SYSTEN-]INC.I OUTLETS I (PARK FEE Y N
3800,Lab C.)
Policy N -- - --- RECEIPT N
Coro any GAS F.A.SYSTEM-0VER4(EA) BUILDING D I VI SION FE ES I
�Certlfied copy is hereby furnished. GREASE/INDUS[AI,WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE7RAP I PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200Ff I Date Receipt#
(rhla auction need net be completed if the permit Is for one hundred dollars
($100)orlass.) WATER HEATER W/VENT/ELCCTR I ILNERGYFEE Y N
a
I rtlfy that In the perfomanm of the work for which this permit is cawed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING I PAID
Workn
e 'Compensatlon Laws of California, Date
Pa I SQFT. I Date Receipt#
Applicant
Z 5 NOTICE TO APPLICAM:If,after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB.
should become wb)ea to the Workers'Compensation provislo s of the Labor TOTAL:cn Code,you most fort hwdh comply with such provbwm or this permit Shan be I
W > deemed revoked. 'lUILDING FEE �+%1a
EL o CONSTRUCTION LENDING AGENCY I �i rSEISMIC FEE
Z IhembyaM list them via nttmmon lendingagency forthe per form) TOpA �SW tLE_CfRIC FEE
7 enrea(the workfarwhlchthis permit Is Issued(Sec.3II97,CIv.C.) '! --
U O Jonde..N.• _ _ PLUMBING FEE
LL. I— Lender.Aedtees — - QT'Y. 'SST ;MECHANICAL'PEAMIT -ti!' `,}a FEES°-MECHANICAL FEE
O W Icertifythol havereadthisapplicadonand StatethAtheabove in formation PERMIT ISSUANCE I FEES PAID:
C 6rorrect.I agreeto comply with all city and county omnnancesini state lawn
} W relating tobuliding comiroman,and herebyauthoriaerepresenta iveso(thls
f-. U) city to enter upon the above-mentioned property for hapecibnpurposes. ALTERORADDTOMECH.
(We)agree m save,indemnify and jump harmless the City of Cupertiw Date Receipt#
V
against liabilities,judgments,mtsand expenses which may in anyway accrue) AIRHANDLING UNIT(TO 10000CFM) I I SUBTOTAL: I
gaioat sa'd Gt to ce ence of the granting of this permit.
1 � % AIR HANDLING UNIT(OVER IO.000CFM) CONSTRUCTION TAX
Signs plies EOlRraetor IXHALS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZ IIOUS MATERIALS DISCLOSURE I' Hl
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(170 100,ODO BTU!) I Date FAIkAelpt#
matetl lasdefnedbythe Cupertino Municipal Code,Chapler9.12,mdtht, -- -- - `
Ile❑alt Y.and Safety Code`Sectiion 25532(x)2 HEATING UNIT(OVER 100,000 BW I TOT- AL:�'I-,SsZ
o
Will the applicant or❑❑future budding occupant use equipment or devices VENTILATION FAN C31NGLE RESID) 1 f Fj ISSUANCE DATE
which coat hamrdous air contaminants as delimit by the Bay Area Air
• Qaalny Mawgement Distntt? BORER-COMPOHPOR IOLD(U BTU)
4 Y. �No city cf fupe�t'a '-
the 2have read the hua ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
IBoma Health&Safety Code,Smlms 25505,2553]and 25534.I
undcntandthatdthe Wlldingdoe.natmmently have atemnf that It Leroy NEW RISIDFNTIALMECH. 5Q F7.
responsibility to nal(y the occupant of the requirements which must be met
prior to issuance of a Certificate of Ocoupancy.
a
Owner or awhcr,red agent Date ISSIJCABY: h/� �
TOTAL:
OFFICE COPY