22247 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Addses°
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_AP a 8 Q CITY OF CUPERTINO-BUILDING DIVISION1
C.ntractora Name: .1 Lic.No: APPLICATION / PERMIT @ �( L
BUILDINGELECTRICALPLUMBING-MWLAICAL CATEGORY CONTROL My
Il
A / nnr. No: - N
pY��ss/ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrux.% 8/-IIWI Sr Sa F 94 IDS- PERMTISSUANCEww2�c ���U
LICENSED CONTRACTOR'S DECLARATION W '-/--
Ihereby
affi.thatI mUmaeduMerpr Wonsof Chapter9(mmmm APPLIANCES-RESIDENTIAL JOB DESCRE'TION
Ingwith Sedion7000)of Divbion3ofthe Buslnnsand ProfeWmoCode,and my
Ilcensa le In fug fnorand effect. PANELS �� ',w WIt�
License Clam Lk.M /"� `i -
Date Contnctar —UP TO 200 AMS
ARCHITECTS DECLARATION 201-1000 AMTS
rc t O I and d labaggy a used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
6i z E Linen Iona - SIGNS
WI ELECTRICAL �D I N
<G a Lau h R.BUILDER DECLARATION SPECIAL CIliCUIT/MIST
F, Iherebyace, (S-clam exemptlroossa ContractorsLicense law fore he ���
2p � followingreason.(Sectionrndtw Budnemandrimp ons Code:Any city or
O 2,f:� TF]sU'.METLROR POLE]NST.
K ca uaboccohrequlmapmm�ce, is requires the
impmvgdemsuch,arto
IN
atmeture statement
that he Is also and pursuant t the pro inionsuch ofpermit e POWER DEVICES ��.-s
Oce a signed statement that he 4 1loenaed pursuant it the provisions o! the l_�./
Oa DATE
IonlolthaLicense Ld(Chapter9(mm)ortha withmRionhemfof and
" �O� don3o(the Budnnaand ProfemlomCode)orthdhebexempt[herefromand SWIMMING ivi- POOL ELECTRIC pusevow
the basis for the alleged exemption. Any violation of Section 70!1.5 by anyUTLETSSWITCFffSFIKTURES-
applicant fare permit subjects the applicant to a civil penalty of nor rrecrethan c o0
o Ove hundred dollars(4500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
W rl I,ae owner of the property,or my employees with wages,as their sole
mmpnuation,will do the work and the strutlure/s nor Intended or offered for
mie(Sec.7044,Bush, ..od Professions Code:The Contractors Liceem,Law
$ don not apply to an owner of property who Wilde or Improves therron,and OCC.GROUP RES.AMTS
whodonsuchworkhimselforthmugh Msownemployeee,provided thatsuch
Improvements arc not intended oroffered!wine.If,hawever,thebuildingor TOTAL:
Impmwmontbwtdwithlnoneyearofmmplefon,theowner-bugderwgl have
t"rden of proving that he did not Wild orlmprove for purpose o(sale.). QTY. PLUMBING PERMIT FEE
LJ I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractore to construct the project(So,7014,Husinemand Profestaons Code: ]PERMIT ISSUANCE
The Contractor's License law don nor apply to an owner of property who ALTER-DRAIN hVENT-WATER ff-N
builds or Improve re
theon,and who contracts for such pm lojewith a FEE SUMMARY
o9jil actor(a)Roomed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec 0 k P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Data RpCpIPT p
WORKMAN COMPENSATION DECLARATION FO(TURF"S PER TRAP SCHOOL TAX Y_ N_
QI hereby affirm that 1 have•certlRcete of consent ul self-insure,or - RECEIPT a
u00,Labrtificate o(Worken'Compenatlonlmunnce ora certifkd copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Policy
Lab C.)
Polley R BUILDING
N
GAS EA.SYSTEM-0VER 4(EA)
' Com any BUILDING DIVISION FEES
�Certlfied copy b herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Ca. d copy b ffledh.ra with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANRAAY-STORM EA.200FT. Date Receipt#
RMssedton need nor be complated 1f the permit b for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythet in the pad..nceof the work for which this permit In issued,
I shall nor employ any person In any runner an as to become subject to the WATER SYSTEM/TREATING
Workera'Compensation Laws of California.Date PAID '
0 Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date - Remi f#
Z O NOT[CR TO APPLICANT:If,after nuking this Certif o(Exempdon,you ,
should become subject to the Workers'Compenmtbn pmvbbm ofthe Labor TOTAL:
f�) Code,you=at forthwith comply with such provbiom orthb percNl shall be
BUILDING 3 7.
W �j - deemed revoked.
d 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE 60
I hereby affirm that there b a construction lending agency for the perform ELECTRIC FEE
7 Z anCID
ofthe work for which this permit is houd(Sea 3097,Civ.C.) TOTAL:
C.) 2 Lenders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythat I havereadthb applicellonand datethattheabove information ,.�s-�
a #correct.lag! tocomplywilhaURtyandcounlyerdlnanuse, date laws PERMITISSUANCE FEES PAID:
} N relatingtobullding mmbuRlon,and hereby authorize representatives ofthb 1
I.. city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
` Date ' Receipt#
Z (We)a .cove,indemnify an d keep harmless the City of Cu pertlno
agaleatlb t ,jidgmentsmds ea nen witch nuyln ywayamue AIR HANDLING UNIT(T010,000CFM) SUBTOTAL:
agairot d tyle ronaryu h esti o hla pe
73� AR HANDLINGUNROVER10,000CFM) CONSTRUCTION TAX
Si ppUcent/Contractor Date EXHAUST HOOD M/DUCT, CONSTRUCTION TAX PAID:
`1=DOUSMA LSUISCLOSURE
Will the applcent or future bu Ud pantstore or handle hazardous HEATING UNIT(TO 100,000 BTU] Date Recei t#
outurial as dellned by the Cupertino Municipal Cade,Chapter 9.1 2,and the -
Health aedSafety Cod eSection 2S532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAC7j'TiSU
11I—IYn MN. VpNTDLATION FAN(SINGLE REBID) ISSUANCE DATE
11 the hacardapplicantuor!.curebuildingoccupantum Nu ipmentor devices
which eMahaementsairrict? arab as deOned by the Bay Area Air p�M
Quality Management IXstriR7 BOILER-COMP(3I0'DR 100,000 BTU) Cir
Yca ❑No /br
hoveread.i.Hh.th&Som materials of BOILER-COMP(OVER 100,000 BTU)
the understand
that lith k building
Code, of currently have a tenant,
ands,that I JUL 3 O 19$1
mponsanlityto(tify the occupant note require encs which must
it bray NEW RESIDPN'IIALMETH. SQ.IT
prior to
c of
the occupantofthe requirements which must be rant ,
prior to Lmuanre W a Certificate of Omepanry.
Owner.,authoslmdagent Date ISSIIEDB
TOTAL:
OFFICE COPY