22289 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
1 tluildln I•r t Identification PERMITNO.
BuBdin A 2228.9_
e A A
CITY OF CUPERTINO-BUILDING DIVISION
C°^ APPLICATION I PERMIT S—I-I_q'
t� BMLDINC-ELECTRICALML BINGMECHAMCAL CATEGORY CONTROL If
Rf Lie.No:
/w�� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: VI [/ PEtMITISSUANCE ❑ ❑ 7�—N
LICENSEDCONTRAcT 'SDECLARATION �J
I hereby affmnthat l am Loosed under provisions of Chapter 9(commenc APFLIANCESRESIDENfIAL JOB DFSLREInON
ingwlth Sccd..70W)°f DWh&.3o(theBudneaa P fe slonsCodq and my
licensebin toll ef(ttt� PA 2 '
License I LIC#
Date Contractor
ARCHITECTS DECLAR N MI-1000AMPS
W0 I understand my pians shall be used as public records OVERICWAMPS 'X.J10(2R0 ' S/SQ.FT.
�E Licensed Professional SIGNS ELECTRICAL /lw�� LL CCCe
MPU E
<cV1. OWNER-e UILDER DECLARATION
SPECIAL CIRCUIT/MLSC
,I.., Z Ihcrebyaffirm tFatlace exemptlmmthe Contractor's License Lw(orthe
Kyy following rtason. 7(DLS,Buslneo and Pmfesbv Code:My city or /y /
Z�"'u9 countywhlchrequlmsapermittommtmd,altegimpmvgde=llsh,ormpair �P.MEIPR OR POLE INSI'.
anyslrutture prlorto its Issuance,also requires theapplicant forsuch permit to POWER DEVICES .
CFO file a signed statement that he is licensed pursuant to the provisions of the
Doi Contractor's Liceve Law(Chapter9(mmmentlng with Section 7000)of Divi- SW3,1MING IDOL ELECTRIC
GG slon3 of the Business and ProfemlonsC°de)or that he is exempt therefrom and VALUATION
�°^I the basis for the alleged exemption. Any violation of Section 7mu by any
�0= appllantfora permit subjedsthe applicant to a dvil perullyofnd nomthan OUTLETSSWITCHESFiXTURES
$ five hundred dollars(5500).
],as owner of the NEW RESIDENTIAL ELECTR SQFT, STORIES TYPECONSTRLGTION'
? n ❑ property,or my employee,of In wages a thele role
com(Sec.74k BusdosM1 awok,and the sirude: hnot Intended oroffend for
k o
sdoes ale(notap lytoaness ownerofpro arty Code:The Contorim rovrsthemoelad
(j$$ whodotinuchoan ownerofpmpertywho
nemocces,prvideereoRand OCC.GROUP RES.UNITS
wprovemuch am nowork r
rosendedoroughhisowne.If,ho evert the building
or
improvement,artnot Intendedorof/ec locale.ILhower- thebuildingve TOTAL:
Improvement baold wlthinoneyearofcompldlon,thcowner-W llderwlll have '
t Men of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contrad.m to construct the project(Sec.701#,Business and Pronfeo.Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VFM-WATER(F U
Wilds or Improve.thereon, and who contracts for such ptojects with a
co I ador(s)licensed pursuant to the Contractor.License Law. FEE SUMMARY
�I am exempt under Sec. B A P C-for this reason BACKFLOW PROTECT.DEVICE OUTSIDEFEIS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Xr Date REC=
WORKMAN COMPENSATION DECLARATION FIX.IlIRES PFR.IRAIa SMOOL TAX Y_ Nhereby affirmth I have a comficate°f consent to self-Insure,ora - REGERPT Noteo/Worke vol acertl0e pythereofFee. GAS EA.SYSTEM-1 INCA OUTLETS pARKIEE Y_ N
Lab CJ
PolwyN • CAS EA.SYSIT7M-0VERe(EA) RECEIPT'#
Com any B UILDING DIVIS ION FE ES
edified copy ed. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Ccrtitled copy b filed with the city inspection dlvlCon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWIRLSANITARYSTORM EA.200FT. Date RCC('1 L#
RM1lasectlon neM rad W complded If the pemdt ls foron<hundrxd dollara D
(SI ID)oWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ittrtify(y thahatUthe pedomunttof the work for which this permit blsved,
1 shall not employ any person In any runner an a to become subject to the WATER SYSTEM/,TREATING
workers'Compensation Laws of GRfomb.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Cediflate of Exemption,you NEW RESIDENIAL PLMB. SQ.FT. Date Remi tN
should become bit"to the W°rkeri Compensation provisions of the Labor - TOTAL:
W Code,you at fort hwith comply With...hpmvisionsorthlspemit Mallbe BUILDING FEE
LU ] deem#rooked.
W CONSTRUCTION LENDING AGENCY
CL O SEISMIC FEE
M (hereby affirm
orkfoWichthiaconstrmetion Isignma(Sec.397,Civ.cy C.) perform- ELECTRIC PEE
� Z arm of the work for Which Rials permit Is blued(Sec.3097,Civ.C.) TOTAL:
. U 0- Le^dery N. PLUMBING FEE
LL H Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Tcedlfythatlhavereadthbapplk tlonandstatathatthcabovelnfornutlon
Is correct.l agree to comply withal]dtyand county ordinance.and Cate laws PERMIT ISSUANCE FEES PAID:
} Mating to Wilding construction,and hereby authorise representatives of this
city to enter upon above-mentioned property fns inspection purposes. ALTER OR ADD TO MECH.
Z - Date Recei tq
— (We)agree to save,Indemnify an d keep harmless;the City of Cu ped Ino P
ago Inst liabilities,Judgmenta,cost...d expenses Which may In any way accrue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL:
against mid City In consequence of the granting of this pemdt.
AIR HANDLING UNIT(OVER 10,001)CFM) CONSTRUCTION TAX
Sigruwre of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oo:upant store or handleha:ardous HFATINGUNIT(TO100,0008]U) Date RCCCI tic
material as defined by the Cypertino Municipal Code,Chapter 9.12 and the -
rlaBh and Safely Cede,Spftton 75532(a)T HEATING UNIT(OVER 100,M BTU) TOTAL:
❑Yea 'T-NPq�N0
Will the.ppllant or wre building ocmp.nt.,e equipment ord,vicea VENTILATION FAN(SINGLE RESIU) ISSUANCE DATE
which emit havrdous air¢¢¢¢¢¢ntamieunts as defined by the Bay Area Air
Qu lity Mawgcmnnis NT BOILER-COMP OHP OR 100,lXD Bill)
❑yea No
I have read the haxa amaterlot.r u lmnrnto under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California ItM1A fety Code,So v25505,25533 and 25534. I
undersU at i f the Wildingdoean reently have.tenant,that it NEW RESIDINfIAL MECIi. SQ.FT. PUG
rmpo Iiity to I(y theompantu t mqulremenU ich must be met 1'1 �1
prix a rtifiate of array.
Owncro thoriudage c7 (S
TOTAL: UED BY:
OFFICE COPY