22647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect identification PERMIT NO.
Bnfiding Ad999 ���F, 22647
n ame: one.
CITY OF CUPERTINO-BUILDING DIVISION
G trador's Name: M APPLICATION / PERMIT
�'a!/ ` 4"t: BLnDINGELECTMCA4ML BING.MFCHAMCAL CATEGORY CONTROL
A M/hoWomr. Lk.IS
QTY ELECTRICPERMIT FE-E BUILDING PERMIT INFO
Addrcere PhRhB7ISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby af(Irmthat l amlicensed under pmvislonso(Chaptari)(commanc. APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
ingwith Seaton 7000)of Divlslon3 ofthe Busleestand ProfesslonsCode,and my
License
is In ha a d(ect. al 7-V11"'
� �� PANELS
Liana L L
Date Contractor —UP TO 2DOAMU
ARCHI'IF,CTS DECLARATION IDI-1000 AMPS
aO Zp /I en m platraWll'Ke_u9ed y,publlcrerorde. OVERIOOO AMPS - SQ.FT.FLOOR AREA S/SQ.Ff,
Llcen�i.Pm(emlarul SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION $PECGLCIRCUIT/ML9C
z1.. 7a herebyafRrmtlutlam exemp(romlha Conlndors Liwnse Law forthe
0 qqqqqq
foil Iowing mean-.(Section7m1S,Businessand Pmfenions Code Anydtycr
E'ut coon whichrc requires permit wmmutm TEMP.MEM OR POLE INST.
FE 3 t4, qu pe galstheapmvgt for such
q any atmcturc priorta ste.meitahataance,alemsed pursuant to the ro visionofpermit e
(Ile a signed statement that he Is Ilmneed pursuant to the provisions a( the POWER DEVICES --�
OS Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- .: J V / `, Ice -_y
SWIMMING POOL ELECITIIC
the basis fo thealle edPMealon. Any orlation f exempt therefrom and _ VAL ATION
0
the basis far the alleged subjects
th exemption. Any violation of Salton 7o,m ,any OUTLETSSWITCFTF_SFWTURES' e � � i 11 '.I E
applicant fora permit eubje b Ne applkanua a tlWl pvultyo(nat morethan i!
R five hundred d011ars($SM. 1 NEWRFSIDENDALELECTR SQ.Fy'. �STgMrs TYPECONSIRIICTION
7< FIT,as owner a!the properly,or my employes with wages as their sole
compensation,wllldothe work and thesutu ure Is not Intended m offered for
❑
.1.(Ser.7044,Dust..and Pm(caskma Code:The C.mmdola Ltrese Law _
�9 does not apply to an owner of properly who builds or lmpmves thereon,and
soh.dossuchw.,khimselfwthroughh[sawnemptoym providedthat=ch OCC.GROUP RES.UNITS
Improvements arc not Intended oroffered for sale.If,however,the building or TOTAL;
Improvement lsauld within oneyearo(compltkn,the owner-builderwill have
lh�*rdan of proving that he did not build or improve for pu rposa of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as,owner of the property,am exclusively contracting with licensedPERMITISSUANCE .^n
contractors,to construct the project(Sec.7044,Buetru m and Pmfessiom Code: C.A./
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT
builds or Improves thereon, and who contracts - -WATER(EA)for such pkajects with a
cgBjpdor(s)Bansd pursuant to the Contndoes License SUMMARYnse Law. RACY FLOW PROTECT.DEVICE
IJ ec I am exempt under SB k P C for this reason
R ARE�,C COND. M_ SANITARY Y N
• Owner Date DRAINS FLOG ROOF, Cr��
WORKRECEIPT
MAN COMPENSATION DECLARATION IrDaURES.PER TRAP SCHOOLTAX Y N
❑1 hereby.(!less that I have• Insure to of consent to op thereof(Sa RECEIPT M
3800,Lzte o(Workers'Compemuatlon lruunna ora certified copy thereof(Sec. GAS EA SYSTFAII INCA 0UTLLIS a CZ PARK FEE Y N
3800,Lab CJ 1
Policy p DINGRECEIDf N
Cam any GAS F.A.SYSTEM-OVER6(FA) :S BUILDING DIVISION FEES
Certified copy is hledwth theI.cid. GREASE/INDUSIRL WASTE MTEtCEPTOR PLANCHECK FEE
❑Certl/ied copy V(Tied with the city inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS- GRFASETRAP INSURANCE PAID
COMPENSATION NSURANCE SEWER-SANITARY STORM EA 200FT Date Rett'1 IM
RhlssecHon need not be comploted if the Tpermit 0for one hundred dollars
(8100)wfy that
I. WATER HEATER W/VENT/ELEc•1•R '� ENERGY FEE Y N
(certify that employ
any dean t ceOf lm work fo as tobehh pesubpar luued, N-
0
shall raw employ any peeson In any manner n ss to become soblect to the WATER SYSTEM/,TREATING //''
Workeme'Compenaatlon Gore oI GlBOmb.Date xq GAJ PAID
O Z NOTICE NEW RESIDENTIAL PLMB. SQFT. Date ReCel tN
Z O NOTICE TO APPLICANT:If,after making this Certl(iwte of Faemptkn,you
Hshould becomesubjed to the Workers'Compensation provleloon ofihe Lobar - TOTAL:
N Code,you=at forthwith comply with such imwieinru or this permit shall be BUILDING j deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FIE
I herebya(fiemthal there b a coatmctlon lending agency for the perform- TOTAL RIC FII
L) Z antt of the work for which this permit is issued 0xc.3097,Civ.C.) s
U O Landers Name PLUMBING FEE
LL I— Lander'sAddreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtifylhatlhovereadthbeppliwtlonandstatethaltheabovelnformation
IL 'scorned.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N mlatingtobuilding mwtmction,and hereby authorize representatives of this
f- Z city to enter upon the abovo-menioned property for Inspection purposes. ALTERORADDTOMECH. Date RecelPtp
V — (We)agree in save,Indemnify an d keep harmless the City of Cupertino
agalriatl Illtka,jadgmenta,cos sand expenses whkh meyloanywayacvue AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL:
agai sal Clty In conxquenceof the gra rating O(this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgnatvreo(Applkant/Contractor Date IX}1AUSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:_
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant orfoome building Occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) Date ReCel tN
rtuterlal as defined by the Cupertino Munidpal Cade,Chapter 9.1 7,and the -
Iiaalth and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: �Z
❑Yes No
Willthea pplicanl or tum-building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS ATI
which emit harardous air contaminants as defined by the Bay Area Air -��eWif:y'
QFuaility Marugement District?. BOILER-COMP OFD'OR 100,0M BTU)
4 Yes q No - 3
have read Health
ar et Code,Sections
2mentsunDaChapter 6.95 of BOILER-COMP(OVEt 1!10,000 BTU)
the Calonsibmta Health k the occupant
Code, f the re requirements
and 25534.must
be
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
raporx Issuance
notify theiate of oftherequimmentswhich must 6s,naR apt
prior to issuance ofaCertificate of Occupancy.
Owner or authorized agent Data ISSUED BY..
TOTAL:
OFFICE COPY