22895 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Add ress: -z13 Z— 22-895
r 5 :35
nere aces: one:
CITY OF CUPERTINO-BUILDING DIVISION C
c° atl°`'; / JIe'N APPLICATION /PERMIT
TPAL�✓I/V"[� ,�f'�OS BUILDING-ELECTRICALPLUMBING- CATEGORY' CONTROLp
Archit.d/Englneer: Lic.No: MECFTAMCAL'
QTY ,,4 LEQTRIG PERMFC 5 • ••''FLH' :BUILD•INGTERMIT INFO' -
Addrcss
PERMITISSUANCE -7 ❑ 1:1 _ ❑
LICENSED CONTRACTOR'S DECLARATION L(—T
Ther by Sectio 700(ttlam Bi.3,fcensed under presiannsof Cssims9de,and e- APPLIANCES-RESIDENTIAL TOB DFSCRE'ITQN
Ingwith Secfion7000)ot Divlslon3ofthe Buelneseand Pmfeaslona Code,and my ,
license le In full and died. O _ �- PANELS I ��
Data Contractor � '
ARCHI= DECLARATION 1-1000 AMPS
NOCZOO l understand my plaruahall be used as public records. OVERIODOAMPS SQ%r�\7 l i� '
Licensed Professional - - SIGNS ELECTRICAL G V d' u
6'J> OWNER. OLDER DECLARATION SFFf IALCETCUIT/MISC Na p �j T E
02- ..mg yafnrmthction7 IZ,Business
Professions Code:
Lava for the
0 9G Fp q❑ fonowing reason.(Section 7 tto Bu tmc and Pimpm fie Code:Any city it TEMP METER OR POLE INST. /
q,'�5 countywhich requbesapenMttomro requires th,impmvgdennuch permit
/� / It
file
+
EEEgq �T any a signed paler feits hatheiselse,equlrersuant to the Provisions of to POWER DEVICES TE [[[ J Jl'
6ryG file a actor's statement that he(Chapter 9fiaed pursuant it the Provisions 700D) of the
Q wF.
ConI oftractor'sLicenseI and
Professions
ortlag Is
andivi- SWAIMINO POOL EEE
O J thealobasis for
the alleged exemption.
Professions Any violation f exempt 7MIZ by and VALUATION
E5�n...3333 the basis for the alleged exemption. Any violation of Section ee,m re any
app hundred delta. $SMsubjectsthe applicant tea dull penalty snot more than OUTLE'ISSWITC _
five hundreddollenhepr. - NEW REBID E TR STORIES TYPE CORm-u-CTION
L as owner of the property,oa my employees with wages there sale - �'FT'
.1.(Sc
compeeatcon,wnld Business
ando the work,and Chest odureis he C.at achm'or License L for
O sale(Sec,7046,Buatnese and Professions;Code:The Contradols License Law
032 does not apply to an owner of properly who builds or improves thereon,and OCC
who does such work himaelforthrough his own employees,provided that such GROUP ItES.UNITS
Improvements are not Intended oroffered for sale.If,hcwevep thebuilding or TOTAL:
i provementissoldwithin oneyearofcompldcon,theowner-bullderwili have ,.
thLilorden of proving that he did nor build or improve for purpose of sale.). QTY: •:'PLUMBING'PERMIT `tC.FEE,:. FLOOD ZONE pPN
LJ L as owner of the property,am exclusively mntradln.with Ikenred PERMIT ISSUANCE '
contractors to construct the projed(Sm.7644 Business and Profndoru Code:
TheContractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WA77iR(EA)
builds or improves thereon, and who contracts for such p(ujeds with
r8actor(s)licensed pursuant to the Contractor's Ll...Law. 70EE$UMINARY:'
LJ I am exempt under Sec. B k P C for this..on BACK FLOW PROTECT.DEVICE
Owner - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FDITURES PER TRAP SCHOOLTAX Y N
❑f hereby affirm that I have o lm nc n of consent d self-0nwn,ora RECm'1,p
celleIY#eofWorken'Compersatlon lrsursnceoracertified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE - Y N
3800.Lab C.) /2•Lo? ,� ��'
Pelf c SeP O - GAS EA.SYSTEM- (EA) DING DIVISION
'- Cam anv .��d.._ eU. OVER6
tyI _ BUILDING DIVISION FEES
�Certlne0 copy is heed y I with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
[L}CCBltiad copy b flied with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200171'. Date Recel t#
CThbcti
seon need not be completed If the permit b forone hundred dollars
($100).,1..) WATER HEATER W/VENERGYFEE Y N
m
I corHfythat In the perforance ofthework forwhlch this permitI.issued, ENT/ELECTR —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREAONG
Workers Compensation Laws of California.Date PAID -
O Z Applicant .
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you ' 'mow RESIDENTIAL PLMB. SQJ7. .Date Recel t#
shwidbecome subject to the Workers'Compematlon provisions o(the Labor TOTAL:
�q
N Code,you muse forthwith comply with such powbiors orthb permit shall be BUILDING FE .Vy
W > deemed revoked.
d 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there i a constructionIsissued
d(See. agency for the pedorrm ELECTRIC FEE
7 Z sees?the work forwhichthls permit Is issued(Sec.3097,CIv.CJ TOTAL
V O Iendere Name 77� . . PLUMBING FEE
Iy H Lend.e.Addrees QTY { MEGH,ANICALT$Riv1IT FEE;
O W Icertifythat I have read this application and gate that theabovecnformarion MECIiANICALFEE
S iacoread.Iagreetocomplywlthalldtyand rountyordinancesand ata PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authoice rcpresentat soft -.
H Z citytoenlerupo he above-mentioned property for Inspection- rposes. ALTERORADDTOMECH.
_ (We) o save,indemnityan d keep hamde he C of Cu in. Date Receipt#
against Is ' dgmente,cosreand expenses me nanyw mrue AIR HANDLING UNIT IT010,000CFM) SUBTOTAL:
against ser Ci In xyus.of the gran thl melt.
�. AIRHANDLING UNIT(OVER I0,OOf1CFM) CONSTRUCTIONTAX
Si atureof App ,onrractor - Dat EXHAUSTHOOD(W/DUCT) CONSTRUCT ION TAX PAID:
HAZARDOUSMATERI DISCLOSURE
Willtheapplies for futurcbu dingo ipant store or handle hazardous HEATING UNIT(TOl00,000BTU Date Recei t#
material as defined by the Cu Ino Municipal Code,Chapter 9.12,and the
Health and Safety Cod a on 75532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yee No
Will the applicant or form,building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which'emit ha..leasair mntamin defined by the Bay Area Air
Quality Management Dish BOILER-COMP OHP OR 100,000 BTU
Yes o
have read Health
a Sus materials requi 25505, udder Chapler6 0(, BOILER-COMP(OVER 700,000 BTU) . q
the Galland FlealihbSafety Code,Sections 75505,25533and .I
and tans ati(thebulldingdoes net cvrrcntlyh veer tcnan at my NEWIEMDEN ALMECIL SQPT. .Ri k4 'e 1 D(
respors lonolifytheoccupantoftherequ is wh mu emet .{7
priorta u aCertincateefOcmpa City Of Cu�B(I!P!6
tt^
Owner ora [ ae. ISSUED BY: r \A. VI(/
OTAL:
OFFICE COPY