22441 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Protect Identification `. PERMIT NO."
Building Addreas:Os .moo - � k - 22441
Owner ante: Phone: - A
Ips 3.— e CITY OF CUPERTINO-BUILDING DIVISION
co trado shame: _ SC m.No: APPLICATION / PERMIT —S
b�t �-/ - BUILDINGELEC TRICALPLUMBINGMFCHANICAL CATEGORY CONTROL If
f Archime/Engineer, Lie.No . .. ,,..
" + ". BUILDING PERMIT INFb
Eti6CTRICPERINIT� �'H$E"'" '
Address: PERMITISSUANCE ,10
LI .LASED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter9(mmmene. APPLIANCESRESIDENTIAL - )OB DESCRIPTION .
tngwith Ser on70fA)of Dlvlsion3ofthe Buslnessand ProfesslonsCode,and my
license Is In full and Mfect. A'1 PANELS �-F t W
Lirense Claes o Lic.p till �L,� (
Daie�_a M%A CHITIC
�a �s��^"'�I�IARCHITEC WRATION 201-I OOO AMI'5
ni le, understand my plans shall be used as public records. OVER 1000 AMPS - $/F2.FT.
'Cd,
Licemod Profeaeional SIGNS ELECTRICAL �//�1
6 m OWNER-BUILDER DECLARATION I Y! UTEF
I hereby afflrenthat l am exemptfromthe Contractors License law for the SPUCIALCIRCUIT/MIST a
Zp �' following reason.(Section 7031.5,Business and Professions Code:Any city or '� Z
O Z` TFMP.METER ORPOLE INST.
countywMch require is pseancucoorequissihemprove,demoWh,ormit to )
4 any atmdure priorto atements that
he is Beamed
pursuant to the provisionorsuch s
of the POWER DEVICES
f5 tion a signed statement that he t r 9fined pursuant it the tion 7000) of the
W6Ou, Coell ofteLicense Law(Chapter9(mmmentlng with Sectionherafofand
�n SWIMMING POOL ELECTRIC
sio�0� the basis for
the ess alleged Professions Any viothat lation f exempt therefrom and _ VALU I10N a
G the basin far the alleged exemption. Any violation of nattySectiono net room
by any OUTLETSSWITCHESEXTURES V
flapplicant fora pearl subjects the applicant to a dull penalty of net more than v
five hundred dollars r NEW RESIDENTIAL ELECTR.
I,as owner of the
he pproperty,or my employees with wages as their aloe sQ.FT. S RIES TYPE CONSTRUCTION
compensation,wllldolhe wwk andthestmamre brtM intended or offered for
Osale(Bac.7064,Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who beliefs or improves thereon,and OCC.GROUP. RES.UNITS
_ who does such work himself orthrough his own employees,provided that such
improvements arc nM intended oroffered for sale.I(ho vavep thebullding or TOTAL:
improvement bandit withinoneyearofcomplation,theownerbu0derwill have
the burden of proving that he did not build or Improve for purpose ofek) QTY, 7PL54RNGPERMIT ;';FEE-"¢ FIADD ZONE APN
M L as owner of the property,am exclusively contraMing with Ilmnan. PERMIT ISSUANCE
contractors to mmtm&the project(See.7044,Business and Pro(essloru Code:
The Contractors L1rence Law does net apply to an owner M property who ALTER-DRAIN&VENT-WATER(EA)
'
Wild.or Improve.thereon, and who contracts for such ptojects with a - �}°FEESUMMARYi + '
a[(ador(s)licensed pursuant to the Contractor's License Law.
C1BACK p[AW PROTECT,DEVICE
LII am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT R
WORKMANCOMPENSATIONDECLARATION pT%'IVRES PFFI2 TRAP I1 SCHOOL TAX .Y_ N_
❑I hereby affirm that I have a rertificate of concent to self-insure,or a (�D RECEI k
3800.Lab C.7
certificate ofWorkeri Comperuatlon l�uuranre ora rertl(kd copytherem((Sec: GAS FA.SYSTFM-t INC.40UTLFTS 1nI PARK FEE Y N
- d✓ RFCE'Tp
Policy N GAS G.SYSTEM-OVER d(EA)
Com any BUILDING DIVISION FEES
[ .ertlfied copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date- Recei t#
(Chis section need not be completed if the pent Tsforonnhundreddollars .
($100)orlem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work forwhich this permit Is lasend, '
I shall not employ any person in any manner so set to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
0 Z Applicant NEW RESIDENTIAL FILMS. SQ.Ff. Date Reset t#
Z 0 NOTICE TO APPLICANT,.IL after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
fA Code,you must forthwith comply with such pmvisiom or this permit shall be
W > deemed revoked. BUILDING FEE Ir
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a conatruRlon lendingagency forthe perform ELECTRIC FEE
Z ance of the work for which this permit is breed(Sec.3097,Civ.C.) TOTAL /- Q SS77
V O Land sea Name -- V PLUMBING FEE
LL F Lenders Address QTY.r`,'*;'MECHANICALPERMIT FEE'.,, MECHANICAL FEE 5
O WIceftifythatlhawmadthsapp11mtionandktaMthatiheaboveinformation --nn
6 is corrcd.I agree to comply with al city and county ordlnancesandstatelaw. PERMIT ISSUANCE I/R/ FEES PAID:
relating to building construction,and hereby authorize rep rean.....ve.ofthie _ -
"(— city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MUCH. -
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
(') against bllitka,rydgments,(Osteon pensee which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against Id City In cmnsque oft a ntin fthispernit•' - AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
7�S C. O CONSTRUCTION TAX PAID:
Sig of Applicant/Contractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCcei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety C lion 25532(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes ' No ;
Willtheapplirant mbuilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which art haeardousair contaminants a.defined bythe Bay Area Air -
-lily ManagerrentDistrict?No
I j
BOILER-CAMP(31{I'OR 100,000 BTU) rW��
Yes �No
have read Health
alt yCoda,Se reons 2555,2553underChapter
and 25534.
of BO[LGR-COMP(OVER 1110,000 BTU) JUL l r t
the Californiaaat if th&Safety Code,Sections 25505,25533 a tenant,
� 1
responsibility
understandt to
thebuildingthe occupant
oft thrently e
encs lenangthat it Is NEW RESIDENTIAL METH. $Q.FT
r®possibility to rarity theompant o(the requlrcmenis which must be mei - ,
prior to Issuance of a Certificate of Occupancy, 4t1'
Owner or authorized agent Data+ iSSUI? u
D BY: V an
TOTAL: �O
OFFICE COPY