22760 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY'.'
Building Pro'ed Identification - -
Building t o �k aj, PFRhIIT NO.
-� - Y - - 22760
wears sate: one: r _ q
p �_ CITY OF CUPERTINO-BUILDING DIVISION
c.rcored-raName: Lic'No: APPLICATION /PERMIT ( 7
r� S BUILDING-ELEC7RICALPLUMBING-MECHAMCAL CATEGORY CONTROL p
Architect/Engineer. Ldo No:.
T'Y t t EJ:EdFRItiPERMtt' i `FttE 0y,
'B,�IIL'L1ING.PEAMI'C INFO
Address: 'tl* s. t. +•,t
PERMITISSUANCE 01 � ❑• ..� _ ❑ .• . :.
LICENSED CONTRACTOR'S DECLARATION El
Ih mbyaHirmth tlamecensed-nderpmvhlonsof Chapter9(mmmeno APPLIANCES-RESIDENTIAL ' JOB DFSCRIPIION.
Ingwith5edion7000)of Dlvlelon3ofthe Businessand ProfessionsCade,andmy
license ism fWl force and
- efecPANELS
LlcenCCTIO r -(S
Dae1O �Contmdo2
- _I r
. /4( ,
ARCHITECTS DECLARATION 701-1000 AMPS
reO ZpO I undere4nd my pons shall be used u public records OVER 1000 AMPSM
sed Professbnal, - SIGNS ELECTRICAL '
m
OWNER-HOLDER DECLARATION
Zs, -Thereby a(Rrmlhatlam exem)rtfrom the Contractor's License Law for the SPECLILCIRCUIT/MISC
0 9� following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST. UTER
K� �, county which requires a permit to congrock,alter,improve,demolish,or repair F�
W6
any strocture prior to tatemeit that he is also sed ires the pursuant t the rovesior hpermit a POWER DEVICES O�V file a signed statement that he b Ilennsed pursuant to the provleloru of thew0Contractors License Law(Chapter9(commencing with Seddon 7000)of Divi- SWNSMING POOL ELECTRIC Tthe Business and ProfessWwCede or that he b exempt therefromand _ ypLUgthebarbfor thealleged exemption. Any violation of Section 70315 by any '
pTnfiapp@ant for a permit subjects the applicant to a civil penalty of not m-rethan ETS5WITCFIFSFIXTURES Al"
�eeyy five hundred dollars($500), NEW RESIDENTIAL ELECTR
(d�^�n ❑1,as owner of the property,or my employees with waged as their sale SQ.FE STORIPS TYPE CONSTRUCTION
compensation,will do the work and the structure b not Intended or offered for
q sale(Sec.7044,Business and Profeaaloes,Code:The Contractors License Law
doesnmapply to an owner of property who builds or improves thereon,and .. - OCC.GROUP RFS.UNITS
who d-eeeuchworkhimself orthteugh Msown employees,providecithatsuch
improvements arenot intended oroffered for;ale.If,howevepthebulidingor TOTAL: (fatly'
Improvementhsold wlthinoneyearofcompleWn,theowner-b fiderwillh e
t rden of proving that he did not build or improve for purpose of sale) QTy.;::'.`= uPL'UMBING PERMITxxttt ;;\:,FE$'i';• FLOODZDNE APN
"L as owner of the property,am exclusively mntracting with Iicensed PERMIT LSSUANCE
contractors to conatmd the project(Sec.7614,Business and Prmessidns Code:
The Contractor's License Law does nor apply to an owner of property who
builds or roN
Impves ermcomrade
n, and who for such p1 pI,TER-
-jeda with a DRAIN&VENT.WATER IEA)
c t cor(s)Brensedpursuanttothe C-ntrador',Ldcense Law. $YJMMARY.•t
LJ I am exempt under Sec. _ B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner - Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION - RECEPT#
❑I hereby affirm that I have a adifiate of consent to self-Insure,ora TUR'`-PER TRAP SCIjOOL TAX Y N
certifouteofWorkera'Compens an ranceor a certified copythc..f(Sec. RECEIPT -
3800,Lab C.) GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE„ Y N ,
Policy# RECEIPT X
Com any GAS EA.SYSTEM-OVER4(EA) - BUILDING DIVISIONFEES
&tartlfied copy b he to dee . GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
,. art Certified copy b(IMI with t city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissedlonneed nm bec-mplated lfthepermit hforonehundred dollari SEWER-SANITARY-STORM EA,200FL Date Recef t# -
($100)orleas.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]artitythat In the pedormanren the work(orwhich thbpermlt la'aued,
I shall not employ any person II any manner a as t°become subject to the WATQt SYSTEM/TREATING
Workers'Compensation Lawsof CellforniS. Date PAID
Z Appliant - -
Z 0 NOTICE TO APPLICANT:[f,after nu king this Certifirete of Exempt um"you NEWRES[DENTIALPLMB. SQFT, Date Recei t# .
Fshould become a-bject t-'he Warken'Compeneatlon provlal-nn ofthe Labor TOTAL:
to Code,you rrwstf-rt hwlth comply with such provblare or,this pertmt shall be
lL j deemed revoked. BUILDING
IL G CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
that there b a construction lending agency for the perform- ELECTRIC FEE O
V 0 seen of the work for which this permit b Issued(Sec.3097,Cl,.C.) TOTAL _
Lender's Name }„ PLUMBING FEE
IL H LendarbAddresa QTY c db74CF{ANICAL PRIvi1TiFEE;;
O W ]enrtlfythatl have readthbapplicatlonand statethattheab-vein(ormatlon - MECHANICAL FEE
1 beamed.I agree to comply withatl eltyand county ordinances and state laws PFRMITISfiUANCE FEES PAID:
(A relating to Wilding construction,and herebyauthortze representatives ofthis - Q
Z
city to enter upon the above-mentioned property for inspection purpose,. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu Faction ^V ateeft ceipt#
against liabilities,judgments,mats and expenses which may In any way same AIR HANDLING UNIT(To 10,000 CFM) ' SUBTOTAL:
against said City N roncequenre-(the granting of this penult.
AIRHANOLINGUNH(OVERIa,mOCT•M). . CONSTRUCTION TAX
Signature of Applicant/Contractor pate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliraut or future building occupant atom or handle hazardous HEATING UNIT(TO 100,00)BTU) Date R2ee1 t#
material a,defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 7li532(a)7 r HEATING UNIT(OVER 100ML
000 BTU) TOTAL: C
❑ Yea No
Will the applicant ogr Wm building occupant use equipment or devices FAN(SINGLE RF-SID) • ISSUANCE DATE
which emit hazardous air contandatm a as defined by the Bay Area Alt,
Quality Management District? POR T00,00011M. PAID
4Yes ❑n No
have read the haaard-n,rtalerlais regnlremenb ender Chapter6.95 oPD4100'000 BTU) ���
the California Health k Safety Code,Sections 75505,25533 and 25534.11991
underatand that if the building does not currently have a tenant,that It is myMECH. SQ.Ff.responsibility to notify the-=pant of the requirements which must be rtatPror to ua re a Certificate of Occupancy. h--%9-9cit1,,ofn or t tl d agent Date � ;TOTAL:
OFFICE COPY