22086 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: /�Gn O
86
O G
where sine: one: A A
CITY OF CUPERTINO:BUILDING DIVISION
Co Gra a.4 LIc,No: APPLICATION /PERMIT l
S S BULDING-ELECTRICALPLUMBING-MECHAMCALCA RY CONTROL N(.
Arc ed/Engin r. Ip: Lk No: Y
MIT I
QTY ELECTRIC PERMIT FEE BUILDINGPERNFO,.,^ s�
Add.. FERMIt
T ISSUANCE QO �y ISI
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Beensed under prenislons of Chapmr9(comment, APPLIANCESRESIDENDAL ]OB DFSCRBTION
Ingwlth SeRlon7(XD)anDlvlelon3 o(the Budnessand ProfesYoneCode,and my �e Dom` �� /) vk/4�j
license ts e ton rce deflect PANELS n-OI. �1[
Lken C ®�ffy
Lk,N�
DatConi aUP TO 2DO AMPS
CHITECTS .ILA ATI OVER00 AMPSS
ODOAM
q�q�uu a02 I den ashall be used mpubLLcremrds. OVER]000 AMPS SQ.FT.FLOOR AREA 5/SQ.F7.
EOUz Licensed Professional - SIGNS ELECTRICAL r 2
<<�6 OWNER-BUILDER DECLARATION SPECIAL CIItCUT/MIST (� 2(Jsa rb l
Ihercbyafflrm that am exempt from the Contmoma Lima.Law for the '
following reason.(Section 70315,Business and Professions Gude:Any city or IKw.O'` 1 O
TEMP.Mh7ER ORIOLE]NST. �V'll
pld mantywhkh rcqubesa perMttomrutruct,alter,Unpmve,derrolbh,orrepalr
any structure prlortolts issuance,also requlrestheappliant for such permit to POWER DEVICES
0. file a signed statement that he Is licensed pursuant to the provisions of the
Ow Contractors License Law(Chapter 9(mmnrcncingwith Sect1on700D)ofDWI-
30 skm3 ofthe Busmemand Professi nsCods)orthal hats exempttherefromand SWPIMING R70L ELECTRIC ppp... VALUATION
6 the Gaels for the alleged exemption. Any Wolatlon of Section 70315 by any I'2—OUTLE7SI IFS
SWITCFIXIURFS s 00 / 7/ 70� s 0,
applicant fora permlbubjecis the applicant to a civil penalty ofnot more than LLLVVV
un.=lam(S.rr00).
6NEW RESIDENTIAL ELECIR SQFp. $TORI TYI' C N UCTION
�n 1,aof the property,or maxle NEW employees with wages as their ax
< compensation,wildothework,andthestructurelsnor intended oroffered for �//N��A@L E
O .1.CF.7044,Business end Pmfeniaru Code:The cmaradoe.Lt..LAw
$ does not apply to an owner of property who builds or improves thereon,and V .s.
who does such work himselforthrough his own employees,provided that such
Improvmrcnts are not Intended or offered for sale.IL however,the building or TOTAL: s
Improvement issold within one yearofcompletion,the ownerbu0derwlll have
th&b.nd en of pmving that he did not build or lmprove for purpose of sale.). QTY. PLUMBING PERMIT FEE
u 1,as owner of the property,am eadusively mnending with licensed PERMITISSUANCE �-..��••�t FEED70 PN
contractor to construct the project(Sec.70K Bushes and Professions Code: W
The Contractor's License Law don rat apply to an owner of property who ALTER-DRAIN&VENT-WAIER ffA) 0
builds or Improves Ns,ereuand who coMnds for such p4ojects with a FEE SUMMARY
oillicensed pursuant to the Conlndors License Law. BACK FLOW PROTECT.DEVICE
L�I em exempt under Sec. B&P C for this reasonOUTSIDEFEES
Owner Date DRAINSF R.ROOF,AREA,COND. SANITARY Y_ N_
RECEfPT N
WORKMAN COMPEN5ATION DECLARATION FIXTIII(FSPERTRAp l SO IDOL TAX Y N
hereby affirm that I have•certifiate of consent to sel(dnsure,w a gp��
B
rate of Worker'Compasatlonlmu......nifledmpy thereof Cree. GAS EA.SYSTFM-1 INCA OUTLETS PARK FEE Y N
.1,LaBoo b C3 REC01pr N
Cc
N GAS EA.SYSTEM-OVER4(EA)
Cam any BUILDING DI VISION FEES
Certified copy ls hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection dMalon. ,,,,�� �-,qq ��((
CERTIFICATE OF EXEMPEION FROM WORKERS' GREASE TRAP PAID��I �• '
COMPENSATION INSURANCE g}S,pT(-SANITARY-STORM EA 2(10{,-i• DDRM RVO i tin
(This seclon need rad becompleted If the permit ls(arose hundred dollen
(5100)mftis) WATER HEATER W/VENT/ELECTR ENERGY EEE Y N .00
Icenlfy that In the performanceofehework forwhlch this permit le Weed, I-
I shag not employ any person In any manner an as to become subject to the WATER SYSIPDI/TRGTINO
Workers'Compensallanlawsof California.Date PAID_ (E
O Z Applicant NLIV RESIDENTIALPLMILSQFT. atC Reeei tp
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall he BUILDING e00
LU j deemed revokad.
M CONSTRUCTION LENDING AGENCY SEISMIC FEE OA
]hereby affirm that there b ammtrudion lendingagency forthe perfo rm ELECTRIC FEE s
Z an olthe work for which Nb Permit b issued(list.3097,Civ.C.) TOTAL:
ou
U O (enders Name PLUMBING FEE
IL h Lendee.Aldres QTY. MECHANICAL PERMIT FEE MEC
O HANICAL FEE
WIcedifythatl havereadthbappatlonandatalelhattheabove Nit. �,..4,A�tt
1 imrmo.Iagree to comply with all city and county ordinances and=., 1 PERMITISSUANCE I 0) FEES PAID:
III .relatingtobullding construction,and herebyeuthorlaerepresentatives.(this
F Z city to enter upon the above-mentioned property for Inspection purposes. ` ALTERORADDTOMECH. ♦co
W DOtC Reeeiptx
(We)agree to save,Indemnify an d keep harmless the City of upertlnu
V agalns'IWbiIIlW,pdgmenb,coelsand nseswhich nuy In any ay a AIR DANDLING UNIT UO 10,000 CFM) SUBTOTAL:
III.ug.iruts dCity In con a oft gr tWE a peenit.
7 AIR HANDLING UNIT(OVER lO,IDOCFM) CONSTRUCTION TAX
7erec A plla t/C cto D
EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOUS MATERIALS DISCLOS E
Wlllthe applicant or future building oasrpanl store or Lund le haaardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Code Section 25533(.)? HEATING UNIT(OVER 100,000 BTU TOTAL:_2
❑YaNo
. Willlheapplicat or Wmbulldingo pantuseequipmentardevias L VENTILATION FAN(SINGLE RMD) a ISSUANCE DATE
which emlt haeardous air contaMmnta as defined by the Bay Area Air
)Quality Mamgement Dtsldct7 BOILER-COMP(3111?OR 100,000 BTU '
I—I Yes No
1 Y ve reedlea Fara oua materials requirements underChaptar 6.95 of BOILER-COMP
(OVER 100,000 BTU)
e Callfomia Health&SafetyCode,Senlons 25505,25533 and 25534. 1
- onderetandlhatlfthebuild)ngdcesnotarrenllyhaveate...I,that It is my NEW RESIDENTIAL MECN. SQFr. h!
G� responsibility to not Uy the occupant of the requirements which moat be met
^ priorto Wuance ofa CenifiateofOavpancy. • r
Owner or authorized agent DatIL
e
TOTAL ISSUED g '
OFFICE COPY