22027APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: -
2 2332 B, sfi
PERMITNO.
:' 22027
_
wnera .t� one:
T•G �k.��\'
CITY OFCUPERT1N6BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTMCAL-PLUMBING-MFC LAICAL
APPLICATION SUBMITTAL
l��pe
Y/
Contra or'sName: LIc.N.
3
CATEGORY
CONTR p /,
•A LLM/Englme. Lk. No:
QTY_ • ' ,, ELECTRIC PERMIT,, .,. FEE,
BUILDING PERMIT INFO
_
Addreaa
PERMITISSUANCE t}
TNI
L/J ❑ ❑
LICE mthat ED CONTRAROR'S DECLARATION
Ihehscal. 70thatlam Gcm3ofthe under
usirosand Pe fes ptms9 s,andmn
inlicenseISection 7000)olDlvfect. ftheBualneev/and Proleasiona Code, end my
Lire se le In NB fopv, enAti ntraRor Y /
Lf ARCHITECTS DECLARATION
I understand my playa shall be used as public remade.
APPEANCESRESIDENML
JOB DFSCRBsI'ION
/y�y-[�(�!T�
1 AY •✓ l \ l
PANF]Sr
UP TO 200AM?.S
101-1000 AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
` /11
f�a
S/SQ. Fr. .
�l.t q-�
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affl. that I am exempt from the Contractor's Llnnse Lw for the
logowing reason. (Section 7031.5, Buatnesa and Prolealo.. Code: Any city orTEMP
cmuntywhkh requites a permit to coratroct,.1mr, Improve, debe
any structure prior to lb beuance,abo mqulres theappgcAnt(a such permit to
file a signed statement that he b Bccneed pursuant to the provisions of the
Commutoes License Law (Chapter 9(mm
mentlng with Section 7000) of Divi-
slum of the Business and Professimn, Code) orthat he b exempt therefrom and
the heads for the alleged exemption. Any ttoladl of Setlon70315m any
appgondred apears($S , the applkant toe tivll penaltyof not more than
five hundred dollars (5500.
' I, as owner o(lhe property, or my employees with wages ae their sole
mmpensation,wfil Bothe work end the.tmmm bno intended or offered for
sale (Sec. 7074, Business and Profevioa Code: The Contractors License Lw
does not apply to an owner of property who builds or improves thereon, and
who does such work hlmselfor through Meow. employees, provided that such
rc
Improvernts arc not intended or offered for sale. If, however, the building or
Improvement issold with in one yeamfc enpletlon, the owner-builderwlll have
t) urden of proving that he did net build or improve for purpose of sale.).
u I, as oner of the property, am exclusively contracting with Ilrensed
ronmatlonw
to construct the pmject (See 7074, Business and Professions Code:
The Contractors Liman Lw does not apply to an owner of property who
Hu Ede or Improves thereon, and who contracts for
fur such ptujects with a
15actor(s) licensed pursuant to the Contractors License Law.
LJ I am exempt under Sec B & P C for this reason
Sf+F-CIAL C]RCUIT/M15C
METER OR POLE INST.
pOWEg DEVICES
SWIMMING POOL ELECTRIC
-
VALUATION
..7
OUTLETSSWITCF{fSEXIURFS S�
NEWRESIDENTIALELECTR SQ.FT.
STOIRIFS
TYPE CONSTRUCTION
OCC.GROUP
RFS .UNITS
1
- TOTAL: t
3,
QT. t:r, PLUMBINGPERMIT',,:, Gii' FEE}'
,y
PERMIT LSSUANCE
& VENT (FA)
p(gp D7pNE
ApN
RACK FLOW PROTECT. DEVICE
it.
. FEE SUMMARY
Owner Dare
DRAINS FLOOR, ROOF, AREA, COND.
FIXTUIRES PER TRAP
oSANITARY Y_ N ,
REC= p
WORKMAN COMPENSATION DECLARATION
1 QI hereby affirm that I have a mrtlRcate of consent to wB-;note, ora
certifimteof Workers Comper Hon Wuranceoraceniftedmpythemof(See.
3800; Lb C.)
policy
90OL TAX Y_ N_
RECEPTM
GAS EA. SYSTEM -1 INCA OUTLETS
Y_ N_
Cany
oMCcrtiRed copy b rtlfherebytehed.
�Celed copy withh the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihlunplon need not be completed lithe permit b(or one hundred dollare
($100)rtifytJ
I certify rep Is the person roof Rhawork an as to hthis permit la booed,
I.hake not employ any Lam In any manner w as to bacons subject to the
Worker Compensation Love of California,, Date
Applicant
NOTICE TO APPLICANT: !!,aftermaking thea.tI prteis amptio ofthe you
should become subject to the Warken''Compematlon provislora ofthe Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hercbyaf(irmthat there b a comtroctlon lending agency for the perform;
Pae of the work for which this permit b lssued (Sec. 3097, Clv. C.)
I.endere Name
Lneder.Add rea.
I mertlly that) have madthb applicatlonand statethattheabove information
Is correct.I agree to comply with all my and county ordlna=.atnd pate laws
relating to building construction, and hereby authorize representative of thin
city to enter upon the above-mentioned property Im Ire ectton purpose.
(We) agree to wive, Indemnity an d keep harmless the City of Cupertino
against llabllities, judgrrents, mo... d expenses which may In any w.,..e
a (ruts Cl conseuermoft gra oft
Signature or pplIcam/Contract
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingonvpant store or handle hasardous
matedal as defined by the Cupertino Municipal Cade, Chapter 9.11, and the
Flealt Ynd SafetyCod15e J1oon 75531(.)7
Bllhe applkant or❑future building occupant use equipment or devices
which cont hazardous air contaminant. as defined by the Bay Area Air
Q�Jality Management District?
Ye N-
Tluve read the beanguamateriab requirements under Chapter 6.95 of
the California I lealth & Safety Code, Sections 75505, 75533 and 15534. I
understand that it the building does not currently have a tenant, that It b my
requirements which must be met
re for to Issuance
ce of a Certificate
priortoo(a Certificate of of the req
S F.A.
GASYSTEM-OVER4(EA)
CREASEANDUSTRL WASTE INTERCEPTOR
HUI LDINGGDDIVISION FE
PLANC14ECK FEE
PAI Dg4lgI
Date Remi
ES
/ {,{.
# C` `s
GREASETRAP
SEINER-SANITARY-SNRM EA 100Fr
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y- N
PAID
Date Recei #
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. —SQFf.
IOTA
B
(055
s
TOTAL:
SEISMIC FEE
ELECTRIC FEE
1
t
QTY:. MECHANICAL PERMIT FEE
PLUMBING FEE
,
PERMIT ISSUANCE
ALTIIRORADD TO MF)rH.
AIR HANDLINGDMT(ID 10,000 CFM)
MECHANICAL FEE
FEES PAID:
Date RCCCI [#
SUBTOT L•
t
AIR HANDLING UNIT 10,000 CPM) riR If
EXHAUST HOOD(W/DUCT)
UCPION TAX
CONSTRUCTION TAX ID:
HEATING UNIT (TO 100,000 BTU)
- F}T�tA Recei #
HEATING UNIT (OVER 100,000 BTU)
TOTA .
VENTILATION FAN (SINGLE RESID)
IDATE
,5� ���
M 9
rp{sa as�a�- -_
�BL� y1 4^7rIM�a1/�i lMi!
ISSUED9N LJIC YY:JW`F/IhY.3'—Q N
BOILER -COMP OHP OR 100,000 BTU)
BOILER-CAMP(OVER 100,000 BTU)'
NEW RESIDENTIAL MEIN. SQ.rr
Owner or aulhorl ed agent Date
TOTAL:
OFFICE COPY