22210 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Idaalfkatlon PERMIT NO.
Building Addrtes: p 22210
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e �n2lvul /��'PPI� RED CawT 4j .. ItYVtnit � ,.
iDwran•V.— one:
ie CO vn %4Ie5^ IYIe, CITY OF CUPERTINO-BUILDING DIVISION
cA ten gfnae., � ^/oa4 1 pACATEGORY CON^TC
)l 0 BUfLDINGELECTRICAL-PLUMBINGM" AL
Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ad
PERMITISSUANCE r
LICENSED CONTRACTOR'SD LARATION
Iherebyafffren that l am licensed under provisions of Chapter9(comment APPLIANCESRESID LYJ JOB DTMON
ingwithSa on7000)af Dlvleion3ofthe Budneuand PrufeesionsCode,andmy (((ggg'''[)pIP��[[H{{ -
Lkelicere ICless a EICU nd k« -�� PANELS /
Date Contractor L \o /1
ARCHITECTS DECLAR TION 201-IMO
2: 1 understand my plans shall be used s public records. OVER 1000 AMPS SQ.FT.FLOOR QAREA {1r 7 S/SQ.FT.
hi Licensed Professional SIGNS ELECTRICAL Lj V
G6 OWNER-BUILDER DECLARATION SPECIAL CIRC[AT/M15C I�
I hereleyafOrenthat l am exempt from the Contractor's License Law for the
following reason.(Section 7015,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
county which requiresa permittocomtruel,alter,Improve,demolbh,or repair
11 anyd[mdum Pr rtoltelsmance,ai mquimslheapplieantfmsuchpermitto POWER DEVICES
and file a signed statement that he Is licensed pursuant to the provisiom of the
O6Contractor's License Law(Chapter 9(mmmencing with Section 7000)of DIW- VALUATION ^
0 etoo 3 of the Business and ProfessbvCode)orthat he k exempttherefromand GPOOL ELECTRIC
the basis for the alleged exemption. My violation of Section 70115 by any / / Q
65 apphant for a permit subjects the applicant to a civil penalty of not more than 7CIffSHXTURES /U
five L a.ownerundred
NEW R69 AL ELECTR_SOFT. STO IX TYPE CONSTRUCTION
I,as ownar ll the property,or my employes with wages r their dole
mmpenaation,wllldothe work,and theetrucwre ls net Intended or offered for
� ssle(See 7044,Buslamss and Pro(essbw Code:The Conhanole Llcenae Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
whodoessuchworkhimaelforlhmughhlsownemployss,provldedthat c
Improvements are not intended oroffered forsale.I howevegthe ch T
improvement dwldwlthlnomyearofcompldion,t owner. d
thg�urden of proving that he did am Wii
r Mp efm fatle.).e QTY, UMBING PERMIT FEE FLOOD ZONE APN
L-f I,as owner of the property,am exclusively a g Ilan P ISSUANCE
contndant.coreWct thLP
pro)ect(See 7Bus
No 1 Code:
Ilse Contndols License Law does net ay to owner of no who ALTER-DRAIN kNEM-WATER ffA)
Wed,or improves thereat,and who r or such w h a
m,RlTador(s)B¢nsed pursuant to the Contracts kenx La OAQC F[A PROTECT.DEVICE
FEESUMMARY
LI I am exempt under Bec. B k P C r
a R ROOF,AREA,COND. S Y— N—
. Owner Date FOEII'1'N
WORKMAN COMPENSATION DECLARATION LTA% N—
EI hereby of i m that 1 have a certificate of consent to self-1 re,ora RECEE'Y N
mrtifirute o(Workers Compensation lvurance or a certified copy,t of Ole GAS EA SY I 60IITLETS PARK FEE Y N
3600,Lab C.)
Policy tl RECEIPT N
Cam any VER6(FJd) BUILDING DIVISION FEES
Cedifed ropy b hereby famished. ,/IND SIAL WASTE PLANCHGCK PEE
�CertlBed copy b(Tied with the city inspection division.
CERTIFICATE OF E(EMPIION FROM WORKERS' G EASE TRAP PAIR`J91 (--L=
COMPENSATION INSURANCE SEINER SAMT. Date Remi t#
IThisuctkn need not be compldM lfthe pemdt bfm am hundred dollars
(DII)arless.) fy / TR ENERGY FEE Y N—
I certify that N permit performance ofthework forwhlch this pedt is Issued,
I shell not employ any pecan any manner su s to become dubfect to thn gy TREATIN'G
Worken'Compen,atlon lJws afGlBomla.Data / PAID
O Z Applicant RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making thin Cent flrate of Ezemption,youXW
Fshould become subject to the Workers Compermation provisions of the Labor TOTAL:
N Code,you at forthwith comply with such provlskm or this permit shall be Gam/ BUI NG
LU > deemed revoked.
a C CONSTRUCTION LENDING AGENCY ELE
SEISMIC FEE
1 hereby a(flkf that then is a comtructlan lending agency for the perform- ELECTRIC FEE
Z sore of the work!carwhich this permit is Issued(&c 3097,Civ.C.) TO
U O Lender'.Name PLUMBING FEE
LL F - Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
U Icortlfythatl have read thisapplieatlanand datethattheabove information
O W iscomet.l agree to complywith all city and county ordinance and state laws PERMIT ISSUANCE I 'S �^ PEES PAID:
�. 1 relmingtobuedingconstructloe, nal hereby authonae representa0vesofthb
(— Z citym mterupon the aboxcrxmtianed property fm impaction purposes. ALTERORADDTOMECH. DatC Recei tic
V Z (We)agree to save,Indemnify as d keep harmles the City of Cupertino
agalnat)��blWl ,fudgmentn,me4send expenses which nay In anyway annus AIR C (T 10, SUBTOTAL'
agalna In n ofthe gra nting a(this permit 21��HAlR N 1 CONSTRUCf70N TAX
pIII �licant ontrador Dal to f' IX CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WVP
Will lheappliemt or future building occupant store or handle hazardous HEATING UNIT(To—100,101M Date Recei t#
material as defined by the Cuper ion Municipal Coda Chapter9.12,and the
Health and Safety Code Section 25532(a)? TIN TOTAL: t
Q Yes -PW
Will the applicant or(uWm Wlldingo pantuseequiproentordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous ale contaminants an defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) PAID
Yes' No
have read the hazy sus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) APR 20
the Glifernla Health A Safety Code,Sections 25505,25533 and 25534.I 199
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQJrT y
responsibility to notify the occupant of the requlrements which must be met -L ^ Cllr
prior to Issuance of a Certificate of Occupancy. 1� U
- GuI,C
111'J
Owner or authonxd agent Data SSUED B
Ti I ' u@Fal{,GyI YJi{Ik OFFICE COPYPI"q A I a aA�A/►t Ow N �,