22676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proem ldentlfiatlon
Buildin Address: PERMIT NO.
40 wn/6133 - �-T= 22676
one:
.01 71l�L � aEC�RATION
CITY OF CUPERTINO-BUILDING DIVISION Q ,j �y
�° "tt°"NiReo: APPLICATION /PERMIT T' `
BUILDINGELEC7RICALPLUMB[NGMFfHAMCALCATEGORY CONTROL N
Arc torso/Engineer. o: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddPERhITI55UANCELICENSEDCONT
]hereby af(Irm that lam lkrnseduMerprovblons ul Chapter(rommrno- APPLIANCESREADENf1AL JOB
Ing with Section 7000)of Dlvislon 3 o(the Business and ProfeselonsCode,and my DESCRIPTION
license Is In lull f...rd died. PANELS
License Clam Lkie
Date Contrettor
ARCHITECT'S DECLARATION 201-1000 AMT'S
rex p p I understand my plaru ehaB be usd u public retia OVER]OW AMPS Fr.rypOR AREA y$Q
1&dil Licensed I'rofemlowl SIGNS ELECTRICAL /� II D ' N it
�6 OWNER-BUILDER DECLARATION SPECIALCIRCIlIT/MLSC /—� 1� ���///
7" 3 herebyafR mthatlamexemp lromtheCont actor'sLirense awtorthe ��) I
O 9�.. following recon.(SMlon 7031.8,Business and Professions Code:Any city or J /"]"f' U
p� county which requlresa permit tomrutruct,alter,Improve,derroWl mmIair TEMP.METER OR POLE INST. n
any structure prior to its issuance,also requires the applicant far such permit to r �j /
File a signed seatetrent that he Is licensed pursuant to the provisions of the IOWFR DEVICES PA
Sec Contractors Ll
cc—Law(Chapter 9(mmmencingwith Section 7000)ofDivi.
�OS cion3ofthe Buelnessand Prefealmu Code)orthat heis exempttherefromand SWIMMING POOLELECHUC - VALUATION
<N the bass for the alleged exemption. Any violation Of Section 70315 by any OUILETSSWITCHESEXHIRES
O
applicant fora permlbubjects the applicant to a civil penalty of not ensure ban /� O�.'
five hundred dollars(SM.
I,as owner of the property, y employees g NEW RESIDENTIAL ELECIRSQ,FT, TYPECONSTRUCDON
mm eat) P petty,Orhe em to eum a with Intended as theresole STOE
< pen ory Bulaothew PnefuaNmtmtte:TheCotmetO License
Law
d for
O sdoes ale(Sea apply in anowess dnaf Property Code:The-1imp ,na, hc. Law
j$ whodotapply toanownerolpmpertywhonempor improvvthereoryand
whodvementsssuch am not maededomugh hlaowal,.Ifyms,provided that such OCC.GROUP RES.UNITS
improvementsareern Intended earofea hcwrvcr,tJwb.iIdIrgor TOTAL:
improvement tssdwithvi gthat Oneyx:artbuildori pre �nerefup rponoflllhave
me Lasrdeweer of tNaheamnat wad orlmprooelacting with
Besse QTY PLUMBING PERMIT FEE
I,as toner Of the property,am.exclusivelyBusiness
contracting with licensed E.00D TAKEcOnAPN
The Co on to construct the project(Sec,apply
ly Buainem ami of pro ora Code: PERMIT ISSUANCE
The Contmectore LIomue Law don not appty ct an owner of property who
bu0ds or Imprwn themmry and who contracts !w such p0okm.A with a ALTFR-DRAW 4 VENf-WATER(EA)
Offal
hcensed pursuant to the Contractor's License Law. - FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEET N
Of hereby affirm that I have a certificate Of consent to WIT.Inwre,or �T�S�7�acenifSC COOL TAX Y N
3800,ab of Worken'Comperuatlon Laurance ora certified ropy thereof(Sec, RECEIPT N
3800,Lab CJ CAS FA.SYSTEM-]INC.!OUTLETS
Polity N PARK FEE Y N
RECEB'I N
ropy V hereby famished.
Com ny S GAEA.SYSTEM-0OVER BUILDING DIVISION FEES
�CcrtlOed
�Certitied copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �� ��
CERTIFICATE OF"EMPITON FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE
(fhlaseRlonneed not becompleted lithe permit 13forone hundred dollars SEWER-SAMTARY-STORM EA.200FI'. Date Recei ted
($100)mleas)
I certify that In the performanceofthe work fOrwhich this permit Is issued, WATER HEATER W/VENT/E-ECTR ENERGYFEE Y_ N_
I shall not employ any enon In a manner sou ,�ro w�j'ct the
Q workers Co u0 V Int .Dat! WATER SYSNd/niEAnNG PAID
APrllant
Z 0 NOTICE TO APPLICANT:I,after naldngt !late of Exemption,you NEW RESIDENTIAL PLMB.__SQRI. Date Recei f#
FW ehmld become mbject to the Workencmo nulcat vhlom o(the Labor TOTAL:
_ Code,y revoketlorthwlth comply withsuch provisions orthls permit shall he
W > deemred revoked. BUILDING -
a C CONSTRUCTION LENDING AGENCY SEISMIC PEE -Qa
I hereby affirm that there isa mvtructlon lending agenry for the perform ELECTRIC FEE
M Z ance of the work for which this permit in Issued(See 3097,Civ.C.) TOTAL:
LL Iandret Naive PLUMBING FEE
LL F !.enders Address QTY, MECHANICAL PERMIT FEE
O W Icertitythatl have readthieeppllatlonend et atethattheaboveinformation MECHANICAL FEE
4 Ismnect.I agree to comply withal)cltyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
W relating to building mrmtmetion,and hereby authorize representatives ofthts
F Z city to enter upon the ab°ve.mentwm,property for inspection purposes. ALTER ORADDTO MECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,mstaand expenses which may In any wayacmue AIR HANDLING UNIT(To 10,0D0 CFM) SUBTOTAL:
agal City n ce granting of this permit.
T _ _ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
g ture° APplimn/Contractor Date EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA 7A R DOUSM ALSDISCLOSURE
Will the applicant or future build g occupant atom or handle hazardousM
UNIT 101,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.]$and theDate Recel t#
Ik.hhand Safcty Code, No
NgT(OVER 100,000 BTU) TOTAL: s..ry,�
Yrs 4
Ill the applianl orutum building occupant use aqui pment or d evicesN FAN(SINGLE REM) $'(,Ig(yp(HE DATE
which emit harardous air contaminanbas defines by the Bay Area Aira ,1[I
silty Management DlaMci2 P(7FIP OR 100,00 BTU)
Yoe (—I No. F qp A
have read the h. us terials requhnontnts under Chapter 6.95 ofP(OVE2100,DOO BN) �l '2the Califomts Health&SfetyCde,Sections 25505,25533and25536. 1understand that lithe building does not currently have a tenant,that It is myENTIAL MECH, �.IT.responsibility to notify the occupant of the requirements which resat be metlytB Ns /F.,prior m lsa nee ois CediBate°f Oparq. "'''""ttSS M{& oo
Owner or aulhorired agent
[),to
1�4
TOTAL: ISSUED BY:��
OFFICE COPY