22732 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
B.0diegAddress:
�- 0,hew_ � 22732
wners Name; one: p
1D r?eN6L-A- CITY OF
CUPERTINO-BUIL DING DIVISION
• C ate r'Wsme: - LIc.No: APPLICATION / PERMIT l[
QA IV BUILDING-ELECTRICAL-PLUMBING.MECEIANICAL CATEGORY CONTROL N
Arch ea/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrc ' C Q PERMIT ISSUANCE ❑ El LICENSED CONTRACTOR'S DECIARATION
Iherebyalfirmthatlam lkeneedunderp.Jdmaof Chapter9(mmmenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith5 aton7000)of Dlvielon3ofthe Buslnessand PmfesdonsCode,and my -I
iiunx le In(sal ann� PANTS (7/ GIS
Lken
Coruna
'Date Contractor G
ARCHITECI'S DECLARATION 201-1000 AMPS
P❑?9OQ I understand my plans shall be used as public records. OVERIOOIIAMPS wSQ R�dIIAD .FT.
E o Licensed Professional SIGNS ELECTRICAL I\VI C
<«< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC O, u
7� Ihembyaffirmthatiam exempt(romthe Contractors Lirensa law(m the
following reason.(Section 70315,Buamen and Profeasim.Code Any dtyor ,
Ff'u9 muntywhkhrequlaceaperMttomutmct,a)ter,lmpmve,demolbh,ormpair T' P.MECLAORI'OLE INSf. �s
a anystm=mpdortolbi ame,aIsorequirestheappbmntfmauchpert tto ,C
�a V POWER DEVICE`
file a signed statement that he is lke.ed pursuant to the provisions of the
Conlraam/.Lice..Law(Chapter 9(commendngwith Sectbn700(BofDWI-
30;/ cion 3 ofthe Business and Protessio.Code)orthat heIs exemptiherefomand SWIMMING POOL ELECTRIC VALUATION
Q.•�77 the basis for the alleged exemption. Any WWatJon of SMIon 70315 by any OUTLE7SSWITCHFSFI%7'URES
applicant for a permit subjectathe applicant to a civna
civil pelly dna more ttan
floc hundred dollars($500). NEW RESIDENTIAL ELECTR_SQ STORIES TYPE CONSTRICTION
n I,as owner of the property,or my employees with wages as their sole FI.
C wo,penation,will do the work and the structure Is not intended or offered for
sale(Sce.7044,Business ad Pmf.W.Code:The Contradufs License Law
does not apply to an owner of property who builds or Improves thereoq and OCC.GROUP RFS.UNITS who doe
s.suchwmichimselfmthmughhtsawn employees,provWedthaturh
Improvements are not intended orofferad forsale.If,however,thebuilding or TOTAL:
Improvementlssold withinoneyearo(mmpletion,theowner-budderw111 have -
tllLtlurdenofp.vingthat he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE ,FLOOD ZONE APN
)„J I,as owner of the property,am excNeWely contracting with licensed pp Rl�(/ANCE
contractors to construct the project(Sec.70K Business and Professions Code: '
The Contractors License Law does no apply to an owner of property who ALTER-DRAM&VENT-WATER[FA)
builds or improves thereon,and who contracts for such pwjecta with a FEE SUMMARY
ag0lT�ctoK8)licensed pursuant he the Contractor's Llomse Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. B&P C for this mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
• Owner Date RECEET N
WORKMAN COMPENSATION DECLARATION Fl%'NRFS PER TRAP 54{OOL TAX Y_ N
hereby ork that I have o lm mn of amdif to spythure,m a RECEIPT Y
380D LateofWorken'Compewtlon Wuranre orarertl(kd copy thereo!(Sec. GAS EA.SYSTEM.I INCAOUTLETS PARK FEE Y N
Poli Lab G.l ,e y7 0o z2-�_
DalryY W DINGRECETT
DIN
GAS EA.SYSTEM-0VER 6(EA)
Com v L BUILDING DIVISION FEES
6C Tie copy is hereby—� fu`"1a1"d' GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertified copy Is filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA.200FT. Date ReCel ted
TThissectlon need ns.be complaed if the perndt Is(mone hundred dollars
(3100)orkss3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that N the performance of thework forwhich this permit is Issued,
I shag ns.employ any person in any manner w u to become object to the WATIM SYSTEM/TREATING Worken'CompenssOon Lava of California.Date - PAID
Z Z NOplicant TICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDPN'IAL PLMB. SQ.FT. Date Recei t#
Hshould become subject to the Workers Compensation pmvblom of the Labor TOTAL:
f/) Code,you moat forthwith comply with such provIslors or this permit shall be N
W j deemed revoked.
CL CONSTRUCOON LENDING AGENCY SEISMIC FEE
I hereby affirm that then U a construction lending agency for the perform ELECTRIC FEE
TOTAL:
D z ance of the work forwhich this permit Is Issued(Sec.3097,Civ.C.) Oaa
Yc
U O I.M.I.Name PLUMBING FEE
IL I— lender.Add nvs QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irerlifythatl have read thlaappIlcationand aatethattheaboveinformation
(L accurect.I agree to comply with all cityand countyordinancesand statelaws PERMIT ISSUANCE FEES PAID:
>. N relating tobuilding construction,and herebyaulhoriaerepresentativesafthla
city toamce .Iontheabove-mentlonadproperty(mWpectionpurposes. ALTERORADDTOMECH.
? S.to save,indemnify an d keep harrmese the City of Cupertino Date Receipt#
V aWtl Illtka,)adg.et.,costsandex ch mayln anyway# AIRI;ANDLINGUNTTIT010,000CFM) SUBTOTAL•-
ag= d a e t A l p.pnl MR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
SI sat ppOcant/ mucro ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
I UOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the -
I lealth and Safety Codei clierh 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yesc2fio I
1�
Rill the applicant or future building occupant tree equipment or devices VENTILATION FAN(SINGLE RESIDE CDATE
which emit hazardous air=ismlnards as defined by the Bay Area Air /"Uhl
• Quality Management D��Qbtr}fI�i2� BOILER-COMP OHP OR 100,000 BTU)
4have read thehazaido.materials requirement.under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) SEP 17 1991
the California Health&Safety Code,Sections 2S505,25533 and 25534. 1
under that if the building does not currently have a tenant,that it k my NEW RESIDENTIAL MECFI. SQ.FT.
res Ib ly to notify the occupant of Irementilwhich the Per
or to u of a Cmtllk o! an
G
out odaedo ace
TOTAL: ISSUED 6Y: U
OFFICE COPY