22461 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Praect Identification /1 111--1 PERMIT NO.
Building Address: 1.7 F+ 22461
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afyLfa CITY OF CUPERTINO-BUILDING DIVISION
Com rsName: Lie.No: APPLICATION / PERMIT 1
BUILDINGMECTRICA4PLUMBING-MECHANICAL CATEGORY hQR .`N[J^)
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I PERMITISSIIANCE
LICENSED CONTRACTOR'S DECLARATION I,L1J 1/Js' I(J_
Ihereby affirm that l am licensed under provision of Chapter 9(commenc- APPLIANCE -RESIDENTIAL JOB DESCRIPTION
Ingwdth SectImi7000)of Dtvh,t.3 ofthe Buslnessand Prefession.Code,and m
license Is In full force and effect. PANELS SF�L
License Clam Lica
Date Contractor
ARCHITECT'S DECLARATION 2014000AMPS
ox c records.Zp I understand my plana shall be used as publids. OVER1000AMPS SQ. BOOR AREA f/SQ.FT.
Licensed Professional SICNSELEC / , `�' /
«<�6 OWNER-BUILDER DECLARATION SPECIALCIR
ZV cT/
fp, a I herebyafRrm that l am exempt fmm/he Contractor's License Lw forthe +
OZ follawlogreason.(SMIon70'i1S,Buslnessand Profemlone Code:Anydtyar TEMP.M t NS .
Pr 4 county which requreesa pernottocenatrus,alter,Improve,denioltsh,erespair
yy a nystmmmpMrtalreW ame,alaorequlrestheappUmntfwauchper tto POWER DEVI
W ilio a signed statement that he Is beensed pursuant to the providers of the
0µr Contractors License Law(Chapter 9(commenctng with Section 7000)of Divi- ``
30:1 .don 3ofthe Business and ProfmbmCode)mthat he 13 exempt therefromand SWNLWfl[iPOOL ELECTRIC VAU rat- ,N
k5 O...777 the Exists for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHESHXTURES -�
applicant for a permit aab)ectsthe applicant to a civil penalty of not more than
five hundred dollar($5001,
R NEW RESIDENTIALELECIR_SQFI. SfOWFS _TYPECONSTACTION
GGGG1111 �n I,as owner of the property,or my employm with wages a there sole
mmperwHon,Business work andthestmdurebnot Intended or offered for
O role(Sec. pply to an owner
df property
Code:The Contractors Llcerae law
$ docs not apply torn owner ofp rough who builds
mpoyeprwnted that such
OCC.GROUP RES.UNITS
EE whodoeusuchments am nothimself dedorughhLown ale.If owevrovldedthatach
Improvemenlsarcd withi oneyestrofcdforsale.themonveg deer ldl scar
have TOT I -
ImprovementtssoldsvithinoneyxarofcempldleM theownerbudderwill love '
t14r,blydm of proving that he did not build orlmpmve for purposeofsale.). QTY; PLUMBING PERMIT FEE FLOOD TONE APN
�iyly as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE //yy��
tractom to construct the project(Sec.7044,Business and Professions Code: W
The Cantractors License law does not apply In an owner a property who
Wilds or Improves thereon,and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
cj5actor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
1_1 I am exempt under See B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ '
WORKMAN COMPENSATION DECLARATION REC�'1'a
C]I hereby Ofbm cese
that I have a rtificate of consent to self- FIXTURES.PER TRAP SCHOOL TAX Y_ N
Inert,or a RECEIPT If
certiflceleo(Workeri Compensation lnauranaore emitted copy thereof(Sec. GAS,PA SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) __ RECEIPT a
Policy p GAS EA.SYSTEM-OVER!(EA)
Com any BUILDING DIVISION FE IS '
Cerfiled copy is heed withformatted.city CREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Wpectbn division. 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP r1...a e k C�PAID (.�
COMPENSATION INSURANCE ! 29As
(Thbsection need na be completed l the permit ts for hundred della. SEWER-SAMTARY SCORN FA'X107' Dale Recel
N
Iceutrtifyify that in the performance of rhe work forwhlch this permit is issued, WATER HEATER W/VENT./ELLCTR ENERGYFEE Y�-L7(II w loos
I shall not employ any person N any manner n as to become subject to the WATER SYSTEM/TREATING +J C. T1
Worke.'CompensaHenlawsof Gidfomb.Date PAID V
O Z Applicant NEW RESIDENTIAL PLMB. QFT. Date Rem, the
Z 0 NOTICE TO APPLICAM:I,after making this Certificate of Exemption,you
should become subject to the Workers'Compenaatlonprovision;of the Labor T7 / � TOTAL. t
y Code,you must forthwith comply with suchproviamuorlhtspermNshallbe tue, 360 UIZ-8 LA -U 5 FMS05 J1---� qt pl
W deemed revoked. �^ �Yl
CONSTRUCTIONemIs
on LENDING AGENCY 1V SEISMIC FEE G O >•"'-�'a�
1 C Ihfthb affirm thatthem . trualond(SNg.3Wagency fort) perform IL TOTAL: ELECTRIC FE p
0 2 enceofthework!erwhkhthtspermittslawed(Sec.3lN/,CIv,CJ O �4 5l
LL O Lc.dera�Add Q PLUMBING FEE m
LL Lenders Addmm QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE !
OW Irertifythatlhavcomply sappllnty andcrmayoatthaabavelnformation �ey
4 Escorted.I agree to complywith all and county ordlnanm and slate laws PERMIT ISSUANCE q, W PEES PAID:
N relating to building construction,and hereby authorla,representatives of this
F Z city to enter upon the above-mentioned property for Inspection pu rposes. ALTERORADDTOMECH. Date Revel III
V - (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against BabNtlee,judgmenfs,mkund ezpsnm which maylnanyway.oma AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
p�mu Id Ci Inco a lthe artm dlhi permit. /
P ! AIR HANDLING UNIT 10,000 CFM) - CONSTRUCTIONTAX ([7 /a3
gnature f p cent/ omsador r 4
EXHAUST HOOD(W/DI1CT) CONST g LTAX AI
HAZARDOUS MATER LB DIS If '��l• D
Will the applicant or future building pants an Ic haz nio a IdFAHNG UNIT(TO 100,000 BTU)
Date
matedalasdefined bythe CupertI.Mu.I ode, 9.12,and the .-- -
Heahh and Safety Code Sedion 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL
Yes M No
ei" t
Rill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) EpgTE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management District? BORER-COMP OHP OR 100,000 BTU)
4r��
Yes No z 4 to
havereadlhehn❑ SEP BOILER-COMP(OVER 100,000 BTU)
Ivg�
the Californb Health&Safety Code,Beetle.25505,25533 and 25534.I
understand that If building doe.not currently have a tenant,that it le my NEW RESIDENTIAL MECH. SQFT Clgr asL/tMT„
responsibility to notify the occupant of the milu mmu
eents which ni be met C*Yg IJ"n4
prior to Issuance of a Certificate of Occupancy. S1 1 q0 _ T
Owner or authorized agent Data - ISSUED
'TOTAL: j0
OFFICE COPY