22792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PFRMITNO.
building Address:
(off 4 22,792 .
wnera ams: one: A
' 2 ►� a CITY OF CUPERTINO-BUILDING DIVISION
Contractow� _ LI " APPLICATION / PERMIT �6
Architea/Engineer. Llc.Na: BUfLDING-ELECTRICAI.PLUMBING-MECHAMCAL CATEGORY CONTROL'#
` t •.BUICDIIyG RERMIT',INPC) .
-
Addreas: MUMS
PERMITISSUANCE 4 ❑. '
LICENSED CONTRACTOR'S DECLARATION ❑ -
Iherebyaffirm that am licensed under provisonsof Chapter9(comment. APPLIANCES-RESIDENTIAL jOeD RIPTION.
InenseI ectionInfull force atd offeon3oftheBus(nwsandlProfnalonsCode,and my � �
license is In fuB(orre end effect. PANELS
License Claw LIe.#
Date Cmnhactor
ARCHITECTS DECLARATION 201-luu(JAMPS
q�q�uu 0 CO I understand my plans shall be used u public records. OVER 1000 AMPB W—LU-1
R ARTA §/G,j.PT.
6%d f1 Licensed Professional - SIGNS ELECTRICAL "� -
6 61 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISCX'�4 Iherebyaf( mthatIamexempt(romtheContractorsLicenseLawfortheZQcmntyngreason.(Section7031.5,gu ti sand Professions Code:Any sly it -METER OR POLE INET. Y..,(r0 �" @fountywhleamquirection7edttocosinassandProfproveCode: ny city it � B J� .nanystreeture prierto Its Issuance,also requireslhe applicant for such permIth,of the POWER DEVICESof Divi-mantl ' D'Y'ING POOL ELECTRIC ...- pALUA Nby anyrethan OUTLETS SWITCHESFIXTURES `-
five hundred dollars($50%. NEW RESIDENTIAL ELECTR
�n ❑I,as owner o!the property,or my employees with wages act
Oracle _SQFL STORIES TYPE CONSTRUCTION
C compenaatlon,willdothe work andthe strucNrebnoHntensed or otlneed for /►w
5 O sale(Sec.704y BusNess and Pr°feasioro Code:The Contractors Llrensa Law
S does not apply lm an owner of property wha halide or Improves thereon,and
at such OCC.GROUP RES.UNITS ,
whodcessuchworkhlmsel(orthrough hiaown employees,provldedth
Improvementaare not intended orolfered(or sale.((however,/hebullding or TOTAL:
improvementisaoldwithinomeyearofcomplmion,theowner-bullderw(llhave
Men of proving that he did not build or improve for purpose of sale) QTy, PLUMBING,PERMIT FEE',. }TARO ZONE —A—PN
e.owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
IrIltd.
ctora to mnstrud the project(See.7044,Business and Proftesimu Code '�
ontra or'License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER 03NN
or Improves thereon,and who contracts fee such pwiscts with a
m,➢.tfaao` exemt Me,pursuantmthe Contractor's License&P Law. BACK PLOW PROTECT.DEVICE "``aFE$SUMMARY
' L�I am exempt under Sec. B&P C for this reawn
Owner Date DRAINS FLOOR ROOF,AREA,CON I. SANITARY RECEIPT
#
WORKMAN COMPENSATION DECLARATION
❑1 hereby af(Irm that I have a rertiRcate of consent to self-Insure,ora FLX1l1RES(PER TRA(' V BOOL TAX Y N
certificate ofWorkere Compensatlmnlneuranceora certified copythereo((Sec. 07
RECEIPT#
38W,UbC) _ GAS EA.SYSTEM-1 INC,40UTLE7S PARK FEE V N
P°liryp M` RECEIPT
..
Com any GASEA.SYSTEM-OVER4(EA) #rV BUILDING DIVISION FEES
[-]CeMfled copy is herebyfurnished.the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECKFEE
�Certitied copy Is filed with the sty inspection divlslan.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP URA
I
O
CPAID
OM
-
COMPENSATION INSURANCE - Date Re'ceI tri
sseaimnneed CO be comp)Tif the Spermit UdollarsSEWER SANITARY STORM EA 200PT(oronehundred dollars
($100)or less.)
ENERGY FEE
WATER HEATER W/VENT/ELEC'TR Y N
I rortify that in the performenceof the work for which this permit is issued,
I shall not employ any person In any manner se,w to Become subject to the -
Workers'Compensation Laws m(Calitornla.Date WATER SYSTEM/TREATING PAID .
O Z Applicant
Z O NOTICE TO APPLICANT:If,alter making thCaCertl(Icate of Exemption,you NEW RESIDENTIAL PLMB.__SQ.7. Date Recei pHf
H
W should become subject to the Worken'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. BUILDING ^M
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Thereby a(firm that there Isacorotroalmn lending agency for the pertmrm. TOTAL: ECTRIC FEE
ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O Lenders Name PLUMBING FEE
IL F Iander.Addrew ¢1Y: [ MECHANIC, RM T%
FEE:, MECHANICALFEG
O W Irertlfythatl have read thbapplicationand statethatthe above information -
1 Is correct.lagree to comply with al city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building conahualon,and hereby authorize representatives of this
f.. Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmlew the City of Cupertino - Date Receipt#
against liabilities,judgments,cortsand expenses which may lo.eywayaceue AIR HANDLING UNIT(TO 10,Wo CFM) SUBTOTAL:
against sal 1 in consequence of t a ing of this pe I. _ .
LS AIR HANDLING UNIT(OVER 10,000 CFM) 72;i
, o(A Brant/Co a or Da E)(HAOSTHOOD(W/DUC) PAID:
HAZARDOUS MATERI SDISCLOSUREWill the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000BTU)material as defined bythe Cupertino Municipal Code,Chapter 9.12,andthe I tishealthand SafetyCode Section25532(a)2 HEATING UNIT(OVFA IDQ00D BTU)Q Yea �No - AL:Willthe applicantorfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ATE
which emit hazardous air contaminants as de0ned by the Bay Area Air@+ Ilty Management D❑isMa2BOILER-COMPpFI1POR]OO,IXO BT U)q Yea d No have read the haza musmaterials requrements underChapter6.95 of
the California I lealth&Safety Code,Sections 25505,25533 and 25534. I '#
SEP
#j q
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH.0 �.FT. Fa
re+Poruibility to notify the occupant of the requirements which must be met - O
prior to Issuance of a Certificate of Occupancy. -
Of CU�mO
Owner or authorized agent Date •
TOTAL: ISSUEDB
OFFICE COPY