22134 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address: O OMES7�ht� 2XITY
22134
nera �am�:�/� �J LAA A%/�Yj)I"J7'J �j S ��F, � , OF CUPERTINO-BUILDING DIVISION
Contractors Nana: '^ Lte.No: APPLICATION / PERMIT J 1 I
Architect/Engineer: • [tea Lk.No: BLELDINGELE7CTRICALPLUMBING-MECHANICAL CATEGORY CONfRpf�(�'
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ,Il* s . of
PERhITISSUANCE I INY x ❑
LICENSEDCONTRACTOR'S DECLARATI N .L�SJ /V�
T hereby affirm that l am licensed under provblovof Chapter9(eo.rc APPLIANCES-RESIDENTIALJOB DESCRIPTION
ingwith Senior 7000)of Division ofthe Busincasand ProfessionsCode,and my _
license Is In full force and dfed. PANELS
License Ch® Lk.N I
Data Contractor
ARCHITECPS DECLARATION 201-I000AMPS
µqt ZO I understand my plans shag W used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
E206 Licensed Professional SIGNSELECTRICAL
<�<� OWNER-BUILDER DECLARATION
F, 2Ihtmbyaffirmthat lamexSupt from the Contractor'License Law for the LCIICUIT/MIST ISL I ill A L E ® I N
0Z0 ^ following reason. 70715,Business and Professions Code:Any city or TEMP METER OR POLE INST.
Fou countywhtchrequbesapemtt0000mtmd,xlter,bspmve,dennith,orrepalr ® P
5.a anystmdure prforrolts Lssuance,also requlreathe applicant for such permit to \,J(oJ
E�a a U file a signed statement that he t gcensed pursuant to the poneadau of the TOWER DEVICES
O� Contadoes License Law(Chapter9(commenclng with Section 70BBof Divi- SWIMMING IDOL ELECTRIC
o sion3oftheBusnewand Pro ssbreCoda)arthathetexcmm7f3Ifromand t ATF A' —
{ aplaseforthermitsujetsthapAnyttolrtlonofSection7mISbyany DUTLETSSWITCHBSHXTURE$ �t "tSt9"'�gb
applicant fora pears(subjects the applicant to a dull penalty of not more than
c. five hundred dollars($500).
❑I,aaowner o(the the work and my employees is etwith wages dedor offered
for NEW RESIDENTIAL ELECTR SFT. SIOW65 TYPE CONSIRlKT10N
� < com(Sec.7K B.,noethend Pmf thestrodv:Th,Cntractro immeLaw
5�❑ sale(Sec.7094,Bus Wv and Profesaloro Code:The Contractors license Law
s$ does not apply to an owner of pmperty who Wilds or improves thereoq and OCC.GROUP RE L. IrrS
whodoes suchwork lunselforthrough his own employees,provided that such
improvement arena Intended oroffemd for sale.IL however,the W Ilding or TOTAL: 7
Improvement baekl wlthinoneyearofcompldlon,the owner-builderwill have t
t rcien of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed FlAOD7DNE APNPERMIT ISSUANCE
contractors to comtrod the project(Sec.7044,Businessand Professions Code:
The Contador's License Law does not apply to an owner a property who ALTER-DRAIN&VENT.WATER IPA)
Wilds or improve thereon,and who contracts for such p(ojects with a
co}BTadec or(a)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under SB &P C for this reason
OUTSIDE FF
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a certificate of consent to seg-inwre,or a FIXTURES-PER TRAP SCHOOL TAX Y N
certificate of Workers'Compevatlon Insurance ora certlfled ropythereof(Sec. RECEIPT N
3800,Tab C.) GAS FA.SYSTEM-I INCAOUTLETS PARK FEE Y N
Policy N RECEIPT N
Co ray CAS EA.SVSfFAf-OVERd(EA) BUILDING DIVISIONFEES
Certified copy is heed with the cty GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
'
led copy t(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE yAr (''�
(Thleancttooneed net becompided ifthepermt tforone hundreddollam SEWER-SAMTARY-STORM EA 200FC. Date Rett'1 t# CJaax73
(SIaB)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that Nthe person
maofthe nnek for which this permit t Issued, —
I shall not employ any pesos In any manner at a to become subject to the
O Workea^CompenaHon Lawes o(Callfornla.Date WATER SYSTG/TREAT NG PAID
PP NEW RESIDENTIAL PLMB,
Z 0 NOTICETOAPPLICANT:I(,after rnaklrg,,a Ca,,,aterf Exemption,you __SQFf. Date Recei t#
Fshould become Subject to the Workers'Compensation provtloro ofthe Labor TOTAL:
WN Code,you must forthwith comply with such provisions orthis permit shall he
> deemod revoked. BUILDING FEE L
CL oCONSTRUCTION LENDING AGENCY - SEISMIC FEE
Iherebyaffirenthat there is a construction lending agency forthe perform. ES 7>?,L25
D Z anceofthework forwhichthis permit t 3097
Issmed(Sm. ,CIv.C.) TOTAL: ELECTRICMIC FE
(, O ).ender.Name PLUMBING FEE
Iy antlers Athetl QTY. MECHANICAL PERMIT FEE MECHANICAL FEE l
O W Icertl(ythatl have read thtappRatlon and satethat meabovelnformatlon .-5 t
a tCorrect)agree ompiy withal)dtyand countyonlinancesand State laws PERMITISSUANCE (s GV FEES PAID:
). W relatingto Wild goo trusion,and hereby authorize representativesofthis d/7
F Z city to enter the vamentioned property for inspection purposes. t ALTER OR ADD TO MECH. sW
— (We)agre o ve, ndemnify
and keep harmless the City of Cupedino Date Receipt#
against llabill ,p no s dexpenseswhlahmaylnanywayaccroe AIR HANDLING UNIT(T010,000 CFM)offing SUBTOTAL:
aInc e o he gm oftyp pertnit.�
TT- 2l AIRHANDLINGUNIT(OVERIO,WOCrid) CONSTRUCTION TAX
Sig to ofA If Con Data Ex
Data CONSTRUCTION TAX PAID:
A2ARDOUS MATERIALS DISCLOSURE
Wil heappR ant or future building occupant store or handle hazardous HFATINGUNITOO100,000BIn
T
.ria asdefi by the Cupertino Municipal Code,Chapter 9.12,and the Date Recej t#
Health
fid Sa y Code,Seen..25532(.)7 No HEATING UNIT(OVER 101000 BTln TOTAL s
Wiiltheappilant or❑fumm building occupant usecqulpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP pEIPDR 100,IXq BTU) u`-
Yes ❑No
have read the hazallous material requirements under Chapter 6.95 of BOILER COMP(OVER 100,000 BN)
the Califomla Eieatth&SafetyCode,Sedimu 25505,25533 and 25534. I ( ny J q
understand that if the Wilding does not ce en0y have a tenant,that It t my NEW RESIDEMIALMECH. SQFT. Im�RI N{1 iat7.7a
responsibility to nosily the occupant ofthe requirem ants which must be met
prior to issuance of a Certificate of Occupancy.
Owner or autho fire i agent Date
TOTA ISSUED B .
OFFICE COPY