22077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMT NO.
Building Address: a2 2 0 7 7
,ho
re s: ``one: A GAG I
�+ I✓1 r aS3—!o CITY OF CUPERTINO-BUILDING DIVISION
Celiac` B e ((//.a 1 Lic No APPLICATION 1 PERMIT �2"
t_,VZ7r ccrhsa f 1 / BUILDING-ELECTRICAL-PLUMBINGMECIIANICAL CAITGORY CONTROL Al
qjjW Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Address
iISSUANCE .`�/i ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
the hSydi.affirm(hit laml:censedunder heBugmvLsidPmfe aonsr9 anenc ANCESRFSIDEN]7AL ]OB DFSCRRTION
ingwlth Sect1on7000)of Dlvision3ofthe Busineaand Pro(esslonaCode,and my
license is In form aappp�effect. 6 P
LianDate Class 1W.'11,
DateRepair ,&t.5Tiriy 56=er
Date Contractor
ARCHITECPS CLA ATIOq X1ECTRIC
�2C: I understand my plans shall W used as public records SQ.FT.FLOOR AREA S/SQ.Fr.
dU Licensed Profealovl TRIC6wOWNER-BUILDER DECLARATION iCU1T/MIherebyaffirm thatI am exempt from the Contractor's License Law fm thefollowing recon.(SccHon 7031.5,Business and Professions Code:Any city orcou my which requires a permit to coetmet,alter,bnprove,demolish,or repair RORPOLEIany structure prior to Its Issuance,also requires the applicant for such permit to ICESfile a signed statement that he Is licensed pursuant to the provisions of the0Cntractors License law(Chapter9(commencing with Section 7000)of Divi- POOL ELECTRIC
slon3ofthe BosinessandPro(essloro Code)mrthat heisexemptthercfromand VALUATION
<5 the basis for the alleged exemption. Any violation of Section 70115 by any OUT0 E.�SWITC SFLXTURES a 900�'-
m
pp applicant fora permit subjects the applicant to a civil penalty of not ore than
a g i five hundred dollars($500). NEW RESIDENTIAL ELECTR
q 7 ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
< compensation,wWdotheworkandthestru=u h m mtendedor offeredfor
O sole elec.7O4q Business and Profembw Code:The Contractors License Lw
G 5$ doe not apply to an owner of property who builds or improves thereon,and RF
who does such work himself or through his own employees,provided that such OCC GROUP 3.IATIB
Impmvenrnb are not Intended oroffemd formic.If,however,the building or TOTAL:
improvementisaoldwhhinoneyearofcompiedogtheowner- Hderwlllhave
ilpleortienof pnvingthat he did not build or improve forpurpomofvle.).- QTy. PLUMBING PERMIT FEEpfppDZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE L1
contractors m mrstmet the project(Sc.7044,Business and Professlmcs Code: .La
The Contractor's License Lw does na apply to an owner of property who ALTER-DRAIN&VENT-WATER ffN
Wilds or improves thermry and who contracts for such ptopcb with a
cg0t_[=ctor(s)Bcensed pursuant to the Convactorb Llcenx Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
f_f I am exempt under See. B&P C for this reason
Owner Date DRAINS FLOOR ROOF.AREA,COND. SANITARY Y_ N=:
WORKMAN COMPENSATION DECLARATION RECEIPT p
❑[hereby affirm that I have a certifiote of consent to self-insure or a FIXTURES PER TRAIs SCHOOL TAX V N
a
ce (ia
rtite of Workera'Compensatlon Insurance or a certified roRECEIPT
(Sec. GAS-FA. EM-I WC.60U7LEI5
MOO,Lpb C.) ,O�.m � PARK FEE Y N_
7^ RECEB'r N
Com ray [ GAS PA,SYS EM—OVER 4(FA) BUIL DING DI VISION F Ii IS
�iCenified ropy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certifed copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ER S' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissection need not Wcomplctcd ifthe permit isforonehundmd dollars SEWER-SANITARY-STORM EA.200FT. Date Recel t#
(SI I nemless3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify thato the Person
so as tobthisneertNjis uo the
I shoo not employ any person In any manner so a to become subject to the WATER SYSTEM/TREATING
Workers Laws wa o(Cali(mrnla. Dace PAID
O Z Applicant
_Z O NOTICETO APPLICANT:If,after making this Certificateof Exemptlon,you NEW RESIDENTIAL PLMB._ SQ.FT, Date Recei t#
should become subject to the WOrkers'Compematim provisions of the Labor TOTAL:
~ W Code,you most forthwith comply with such provisions orthis permit shall be B
UILDING 'E
W j deemed revoked.
IL O CONSTRUCTION LENDING AGENCY FEE
= Z Ihereby affirm that there Is a cerstmction lending agency for the perform- IC FEE
once of the work for which this permit IsLsaaed(Sec.3097,C1v.C) TOTAL:
(� O Lender.Nam` NG FEE
U. 1- Lender;Add nrsa QTY. MECHANICAL PERMIT FEE NICAL FEE
O W Icertlythatl have read Isappllatfonand state thatthe above lnformatlon
1 LS I agree to comply with all cityand muntyomdinanresand state laws PERMUISSUANCE ID:W relating to building censtroction,and hereby authorize representatives of thiscity to enter upon the aWeenvmioned pmpnrty fee inspMlon purpose. VNGUNff(OVMj0,00DCr.M)
TOMECH.(We)agree to save,Ind co Ny an d keep harmless the City of Cu ped ism Receipt#
against liabilities,pdgnomts,corns and expenses which may In any way accrue UNITCTOlo,"CFM) SUBTOTAL'
against said City In consequence of the granting of this permit.
UNH(OVFRlO,00DCrM) CONSTRUCTION TAX
Sigwturcof Appilwnt/Contractor Date (W/DUCT) - CONSTRUCTION TAX PA IHAZARDOUS MATERIALS DISCLOSUREWill theapplicant orfture building occupant store or handle hazardous 100,ODO BTU)materal as defined by the Cupertino Municipal Code,Chapter 9.12,and theDate Recel t#
Health and Safety Codon 75532(5)7 (OV 1D0,000 BTU) TOTAL: Qt
❑ Yrs o
Will the dppliunto fuwrebuilding oavpantmu equipment ordevinrs VENTILATION FAN(SIVD
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu lity Management Mct7 BOILER-COMPOIIPOR
4 Vee No
have read the haze oust materials requirements under Chapter 6.95 of BOILER-COMP(OVMIthe California I iealth&Safety Code,Sections 25505,25533 and 25534. Iunderstand that if the building does not corrently have a tenant,that it is my' NEW RESIDENTIAL ME �j'� ,•
responsibilityto oiifytheoccvpa tofthercqulrementswhichmustbemet /-R fYP a .a ^�
prior toicsuamm�,Cemti fl�pm 0fOc pony.
/.l3�' T�'���7� bAm
IF1I
Owner or auth{)necd agent Date �tDIP �) ®
TOTAL: ISSUED BY:
OFFICE COPY