22060APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
I in Pm Identlfkation
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PERMITNO.
22060
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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c t Na
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BUILDING-ELECTR)GLPLIJMBING-MECHANICAI.
CATEGORY
CONTROL N
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QTy ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PFRMITISSUANCE
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❑ ❑ ❑ IN
LICENSED CONTRACTORS DECLARATION
I lrreby affirm that l am licensed under provisions al Cluper 9(oormrcnc
Ingwlth Setbn )of Dlvieion3o n P leWmaCade,and
APIPTIANC6RES3DENTIAL
TOB DESCR=N
lf¢esebm ro�.on�rree. �
GOMfatar _ _ ,.��
DateLkenneC AIt,
ARCHEIECT CLAKATION
rANFls
c,����L�
AMPS
IuMentard my phroehaBbe used spubec remrds
OV OVER1000 AMPS
SQ. FT. FLOOR AREA
5/SQ. FT.
SIGNSELECTRICAL
Licensed Pro esbral -
OWNER -BUILDER DECLARATION
I herebyafgmnthat I am exempt from the Contrutor's Live Law f« the
SPECIAL CIRCNT/h1BC
]LIiP, ME7FR OR l'O ST.
following mann. (Sedlon 7071.5, Business and Pmf ntalomt Code: Any elty or
muntywhkh reerylreea pemdt b mrowt, ilter, bnprmvq demolbR or¢pair
anyatruetue, prior to lb baran¢,abo require the applicant f«such permit to
Ne a signed statement that he is Boenaed pursuant to the proviabro of the
Contractors Lkeree Law (Chaper9(mmmenMg wdh Seerem 7000) of Divi-
slen 3 of the Bushes and Prdesloret Code) or Uai he is exempt therefromaed
POWER DEVICES
SWIMMING LELECTRIC
VALUATION
the beds for the alleged exemption. Any vlola0on of Sedion 711115 by any
fora permit subjete the appllnm to a civil peraRy d n¢ more than
OVIISIS FIXTURES
NEW DENIAL ELECIR SQFT,
fivewndrN dollars (SM.
La.ownu of the property, or my empbn yewith wages u their sok
S RIES
TYVECONSTRUCTION
mmpenaation, will do Eno wmk. and tiumruch re b not bderded or offend for
ale (Sec 70K Buslou, ab Profesbm Code TM Cmur,t.e. Line. Law
dorm t apply to an owner of property who builds or Improves thereon,and
whodceaaurhworkhlmseV mthrough hiamnemploym, provided that uch
OCC.GROUP
RIS. AMTS
Improvemrnts are not Intended oroffered for . IL however, thebullding or
improvement iasald wkhinorryearofc«nplelbm theowner-bullderwill have
TOTAL
ft.hunden of proving that he did runt budd or improve for purpose of ule.).
L u owner of the property, am excb.lwly mntracdng with licensed
mntraton to mrelrud the projet (Sec 7014. Bushes and Profesb,.es Cod
The Contractor', Lkeue Law does not apply to an owner a( property who
builds or Improve, thereon, and who myrata f« such p1jeets with a
q'iPtor(.)B¢ued pursuant to the Comtldtora Limnse Law.
LJ I am exempt under Sec B & P C for this renin
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
/
ALTER -DRAIN &VENT -WATER (EA)
FLOOD ZONE
APN
BACR FLOW PROTECT. DEVICE
FEE SUMMARY
IXUINS FLOOR ROOF, AREA, GOND.
SANITARY Y _ N_
RECEIPT It
Owner Data
WORKMAN COMPENSATION DECLARATION
m
hereby affirthat I haw a certl0nte d consent to .ell -mom,, or a
IBrate ofWorkenC«npe /w�Bo(Jnlsu¢r�¢ or -o' leJd9�gPytherro(6ec.
3800. Iib CJ liT � ��/
Polity I
FO(NRES PER TRAP
SCIIOOI. TAX Y_ N _
RF.Cm7, s
_
GAS EA. SYSTEM -1 INC4D
PARKFEE Y_ N_
RExE]II'I' a
GAS EA. SYSTEM -OVER -R4
Cam y
�Certtft p e�rthecit.
Nedm bfiledwiththetltylspectbndivision.CERTIFLCATEOPD(EMFTION
BE I L DING D I VISION FE IS
RLW IxTERCEPIDR
PLANCHECKFEE
FROM WORKERS
INSURANCE
lithepermRbf«onehundrNdollena]ID)«lam.)
that ionise per(orman¢olthe w«kforwhlch this pematb blued,shag n« ampiay any person N any manner u u to become ubjrt to theWorken'Compreautbn lrassof California. Date
ApplicantALPLMB.
Reuel t#
_PAIDCOMPENSATION
S[ORM PAS.Date
w/VFNT/FJFC
I
ENERGY FEE Y NI¢rtBy
PAID
Date Reeel t#
IREATI
NOTICETOAPPLICANT: ll, ori makingnisi.Cnlon proof Exemption, you
Amid bemrresubh to NeW yr t C psmwbn oro bpeofthe Labor
Code, you mus fmthwkh mmpty with such prwbbv orthb pemdt sha11 h
deemed revoked.
SQFF.
TOTAL:
TOTAL
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyarRmnthat there b a mrawrtlon lendingagesy forthe perform,
nce of the work for which thio permit b isued t5ec. 30Y7, Clv. C3
Leader,
ELECTRIC FEE
woe
Iender,Add.
hmmet. building
Imect. tWA Ihavereadnhbappb¢tbnand sine oh theabovaid( telavat
muntyonllnanmand state law.
Qry. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICALFEE
�GYJ
EE$PAITJ
relying to buildingmroovi,mn,•
oerannywBh.ndhered
hereby dthis
n rtyAorlarepmentativn
ttytoenn Dion the above-mentiomdpmpertyf«Iropecibn rposs.
(We) t sw, Indemnify an d keep hanNes the C of Cupertino
,g, Wt bl t jrdgmenb,ma. upemeawhie mayb ywa ewe
agyst d en¢ofthe etingdthb
ALTER ORADDTOhiFAi.
Date RCCeI f#
AIR HANDLINGUNIT(T010,000CEM)
SUBTOTAL•
AIR HANDLING UNIT 10,000 CFM)
CONSTRUCTION TAX
Slgu ld t/ ontrut« pa
IXHALw HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
IfA2ARDOUSMATERIALSDISCIA RE
Will the applicant or future building oaupent store or handle havadousHFATINGUNIT(10100,000B71n
melerlsl as dcBned by the Cupertino Mu Ntlpal Code, Chapter 9.12,..d the
hkahhard Sa/ety Code SM1on 76324)7
I—I yea,E No
re
Date Rccci t#
HEATING UNIT (OVER 100,000 BT(1)
TOTAL:
,.��
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Bl the ePPI"m on. building occupant use egWpmrM ordevlces
whkh emit harard... air mntambanD.. deRrcd by the Bay Arca Air
BDILEIFCDMP OFB' OR IK"BTI))
Q..lityy Management Dbtrtt2
4have readtheh NomateriabldqulmmenbunderChaper6.95of
w.
PAMP -
BO ER-COMP(OVIXI00,000BTU)
the Calif«nialiealth&Safely Cod,SMbro2&WS,75533and255M, I
understand that lithe buBbur
dingd. not eurremly have a tenant, that It ry
/� IQQ
Aura 7 T 9001
KEWRBDENTIALMECH. SOFT.
raparob0lty to notify the oceupant ol the raqubcmcMa whkh most he met
prior to bsuanee of a Certificate of Oavp, ray.
(�a'aa�asaL
DBY: T' �~
Owner m i:cd authora gent Dale
TOTAL:
OFFICE COPY