22088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address:
�1910( c0 (2T12- �noE2� �N. 22088
wnersa.OP"C� I�n— '`96 U n u�e: CITY OF CUPERTINO=BUILDING DIVISION A
Co ctor'sNanv: Lt..No: APPLICATION / PERMIT
-
Architect/Engineer. BUILDINGSLECTRICALPLUMBINGMECHAMCAL CATEGORY - CONTROL N
Lit No:
QTY . ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I rJ 0D ❑ - �C71 � ❑
LICENSED CONTRACTOR'S DECLARATION C J
t hereby affirm that l em licensed under provisions of Chapter 9(commmc- APPLIANCES-RESIDENTIAL JOB DFSCRE',TON
ingwith Se on7000)of DiNsihn3ofthe Businenand ProfemimsCode,and my ��L--�
it...is in full force and affect. PANELS � ��/�' I . .a�J Q
License Class LIGN F/s^, `�Pw\1.g
Date Contractor
ARCHITECPS DECLARATION 201-1000AMPS
reO ZpOC I understand r'7 plana shag beused u pubtic records OVER 1000 AMPS SQ.FT.FLOOR S/SQ.FT.
U Licensed Profenlowl SIGNS ELECTRICAL %L
E
OWNER-BUILDER DECLARATION SPECIALCIRCUIT MIST L-
Zt,�4 I hereby affirm thatI am exempt from the Contractor's License Law for the / (Y� p U
oo following reason.(Section 7031.5,Business and Professions Code:Any city or 'V'
TER
O Z i. TEMP.MEfTR OR POLE,NST. /���
P5 county which requires permit to construct,alter,improve,demolIsh,orrepair �/ ,
g anystructure petorto tie issuance,alsorequirnthe applicantfm such permitto ppyypg DEVICES
PJ O file a signed statement that he V licensed pursuant to the provisions of the
G613µIn Contractor's Llceree Law(Chapter 9(mmmencing with Section 7000)of Divi- r SWIMMING IDOL ELECTRIC
��0� alon3oftheBusineesand Pro(enbruCode)orthat he Isexemptthere(romand - • VALUATION
the basis for the alleged exemption. Any violation of Seaton 7031.5 by any - OUTLETSSWITCHESHXTURFS
Capplicant for a permit subjects the applicant to a civil penalty of not moreflum
five hundred as
ewnerof thepro NEW RESIDENTIAL ELECTR SQVE STORIES TYPE CONSTRUCTION
�n ❑I,ae owner of the property,or my employees with wages r thele sole
aale(Scompensation,0K will do thmine..e wok and
the
structure Th Contractor.ot License d for
Lave
,, • sale snot apply to anowand fproperty
Professions,Code:The Contractor's License Gw
,pp!!
does not apply torn himself
hfpropertyiso builds hrimproves deereoMand
r'+S^
who dcessuch work Mmsel(orthrough hieownemployees,providedthat such - OCC.GROUP RES,UNITS
Improvements are not Intended oroffered fmsale.If,hhwevegthebuildinger TOTAL: 41
improvement Isshld within oneyearofcompletion the owner-bulklerwlllhave
I enol proving that he did not build or treprove for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE I
otmetors to construct the project(Sec.704ly Business and Professors Code:
-Contractor's License Law don not appty to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such ptojects with a FEE SUMMARY
cgBlladmix)licensed pursuant to the Contractor's License Law. BACK FLOW PROTFLT.DEVICE
I5 I am exempt under Set B&P C for this reason
_ OUTS I DF FEES
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. 'SANITARY Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FD(TLIRES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have• l rtum to of consent to spytheure,ora RECEIPT N
certifireteh(Worken'Comperuatlhn lruurancehra rerti(led copythereof(Sec.
3800, GAS EA.SYSTEM-I INCA OUTLETS �u PARK FEE Y N
If
CO
policyN - RECEIPT N
CAS EA.SYSTEM-0VER d(EA)
Com ny BUILDING DIVISION FEES
❑Certified copy is he d with t e city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
'
E]Certified copy is filed with the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE BEWER-SANCCARY-Stt)RM EA.200Ff. Dale Recei tri
(Thissection need rat be completed tithe the permit Is crone hundred dollars
($100 mlenJWATER HEATER W/VENT/EI.ECIR - ENERGY FEE Y N
I cerblythat in the performance of the work forwhich this permit Is Issued, r/
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATINGC.
Workers'Compensation Laws of California.Date x PAID
Z ZNOTicant I
ICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Oshould became subject to the Workers'Comperuation pmvisiom of the Labor TOTAL:
F N Code,you moat forthwith comply with such provisions orthis permit shalt be
W > deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G I hereby affirmlhal there Is a constmccon lending agency orthe perform~ ELECTRIC FEE19 IbD
O ance of the work for which this permit Issued(Sec,3097,Civ.C.) TOTAL: s a
Lender.Name PLUMBING FEE
F Lender.Addmss QTY. MECHANICAL PERMIT FEE
U. ' MECHANICAL FEE '
O W ,rectify Ngrectatl vereadthis with all cit andeounand aty hattheordinances
cesanbove dformation
IL Matinxt.Iagreeto complywith all ee..ftwa PERMIT ISSUANCE FEES PAID:
r N relating to building comtmctton,and hereby authorlu reprexntativee o(thU
Z d"enter upon the above-menthmax!property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,indemnify an d keep harmless the City of Cupertino
V against babil e,fad nts,easisand espenseswhich mayin anywayacerus AIRHANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agairet said in equence of the granting of this perry, . / AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
2q/4(
q I g 1
Sign.trimW AppBcent/Contractor Data IX}4AUSTFIOOD(4V/DIX:p CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALSoccupa tsmen or handle
Wtllthealas .fined bytheture rttoo ghcmpantode, hapten 91Zanrdous FIEATING UNIT(TO 1p0,00pBTU)
Healtha and
Safety CodeSCupertino Municipal Code,Chapter 91Z andthe Date Recti t#.
,❑1 Ynd Safety Code HEATING UMT(OVER]OO,OW BTU) - TOTAL: l 5
Will the applicant or❑❑future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE .
which emit havardous air contaminants as defined by the Bay Area Air
jP allty Management District?. BOILER-COMP OR 100,000 BTU) nssK '
Yes No PO..oY-�'\'ReJ
have read the hazallous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 23534.I
understand that if the building doesnm currently have a tenant,that it ie my NEW RESIDENTIAL MECH. SQ.Fr
responsibility to naily the occupant of the requirements which moat be reset `0
prior to Issuance of a Cerlifiate of Occupancy. - 1Y
Owner or authorimd agent Data ISSUED BV ��V.A�'aY/—'e'.
TOTAL:
OFFICE COPY