22637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn ee Identification PERT NO.
Building Ad dress: - •
o PERMIT
22637
rare ante: II. one: A
II'1 Cq" tl0 =/D(o -
f. r+ser�.NSame: 6Z s CITY OF CUPERTINO-BUILDING DIVISION
Lie.N : APPLICATION / PERMIT
IoLE
cATecoaY eoN—n oG LC«
Architect/Engineer. Lk Na BUILDING-ELECTRICALPLUMBING-MECHAMCAL
.
ELECTRICPERMIT PEE BUILDING PERMIT INFO, -
Address:,Z,6".Z 'e-.9 Ca- PERMTISSUANCE ( L� ❑ i�� ❑ ❑
LICENSED CONTRACTOR'S DECLA TION �T{
I hereby affirm that l am Learned under provblonsof Chapter 9(comenenc APPLIANCE -RESIDENTIAL JOB DFSCRIPI'ION
ingwithSMion7OW)of DtWsion3ofthe Bupnenand Pmfessiors Code,andm -
Llorr is In full force and effect I PANELS $Sv �I!?,
License Class Lk.c - I `--t/
nate ContractorIT TO
ARCHITECTS DECLARATION 201-10DO AMI r
0O [understand my pisco shalt Wused as public records. - OVER 1000 AMI5 - FLOOR AREA S/SQ.FF.
ki �j Licensed Profe storul SIGNS ELECTRICAL - c ''T
OWNER-BUILDER DECLARATION p r ^
O SPECIAL CIiCI11T/MISC v C ,L•[l
7F, Iherebyafflrtnthat lamexempt(romthe Contractor's License Law for the '
followl^greason.(Section7MIS,Business and Prolenlnns Code:Any city or �(p,ME1PR OR POLE[NSF. /� ^
KQ4 .c°untywhkhmqursapermitt°mmtr m.1ler.krprove,demlWh,ormpair ( q )
0.' anystructure pdorto its Issuance,also rcqutmathe applicant for such permit to ' PO4ASiR. S /
file a signed statement that he is licensed pursuant to the provisions of the j
�Ow�• Contnaors License law(Chapter9(commenWgwllh Section 7000)of Divi- SWIMMING POOL ELECTRIC
�O sion3ofthe Busines.and ProfessloruCode)orthat helsexemp"herefmmand VALUATION
the basis for the alleged exemption. Any vlolati°n of Section 7071.5 by any
applicant fees permit subjects the applicant to a civil penalty of not morelhan OU7LETSS`WITCHFSFfXTURFS
flus hundred dollars(5.50Q. NEW RESIDENTIAL ELECTR SQ.FT. SfOWFS TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
CRz a compensation,will do the work and the structure h not Intended or offered for 1 \�- A-gyp
5 F O sole(See 7014,Business and Professions Code:The Contractors Lt..law
{pj $ due.rm.pply to an owner of property who Wilds or Improves t hereon,and,3 (S r-9 v U,EC' 0OCC.GROUT' RFS UMTS
who doessuch work himself orthrough his own employees,provided that ouch
improvements arc not Intended orolfered for sale.If,however,the building or - TOTAL:
Improvementbaoldwithinamyearofcomplelb tMe ner-WilderwilI have
tl(S_�.rde^ofpmvingthat he did not build or improve for.purponofsak), QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
L j L as owner of the property,am exclusively contracting with licensed
contrsRors to construct the pmjact(Sm 7044,Business and Professloru Code: PERMIT ISSUANCE
The Crntrsctor.Llcerue law does ret apply to an owner of property who
builds ALTER-DRAIN&VENT-WATER(EA)
or Impr°ves thereon, end who contracts such p1°�sctn with a
ovdactoKa)Lcensed rs
puuant to the Contractors License Law. FEE SUMMARY'
LI I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE —•OUTSIDEF-
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECEIPT B
WOR KMAN COMP a comfi ON DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y N_
Qie hereby affirm that I have• imumne of consent to.pytnsurc,ora RECEIPT'N
3800,Iab of Workers'Comperuatlon lreunnce oracertifled copy thereof(&c. GAS..EA.SYSFEM-I INCA OUTLETS PARK FM Y N
Polis lab C.7
Polity N RECEIPT M
GAS CoEA.SYSFEM-OVER 4(FA) BUILDING DI VISION FEES
1 I Certified copy is hereby furnished. CREASE/INDUSFRL WASTE INTERCEPTOR PLANCHECK PEE -
CR�-(yCertified copy is filed with the chy wptt[lon division.
CERTIFICATE OF EXEM PFION FROM WORKER S' GREASE TRAP PAID
COMPENSATION INSURANCE IWFF
STORM EA
SAMTARY- . . Date R
SEWER- eCei tU
(This section need sea Mcompleted tithe Permitkforooe hundred dollars P
(S10()orlen.7 WATER HEATER W/VENC/E[ECTR ENERGY FEE Y N
I certify that In the part....of the work for which this permit la issued,
I shall not employ any person In any manner w as to became subject to the WpTQf SYSfQrt/TREATING
Workers Compenntlon lawsof California. Date PAID
Z Applicant - Date RCCCI (#
Z O NOTICE TO APPLICANT.If,after making thin Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ.FT.
Hshould become subject to the Workars Compensation provisions ofthe Labor TOTAL:
W Code,you moat forthwith comply with such provlslons or this permitshallbe UI
W > deemedrevoked. _ FEE
d G
CONSTRUCTION them6. LENDING AGENCY
1 SEISMIC FEE
I hereby affirmkmfo'wh h t is per
utmctlon d ding(Sec. agency .) perform ELECTRIC FEE
7 Z ante of the work for which this perrtdt b Issued(Sec.J097,Clv.Cd
TOTAL: Z.
U O Lender's Name PLUMBING FEE
LL I— Lander.Add ren - - QTY. MECHANICAL PERMIT PEE MECHANICAL PGE
OW Imdifythat l havereadthbapp0otlo...dpatethat lheaboveinformatlon
1 iscormct.I agreeto comply with all city and county ordinances and pate law. PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives ofthb b
H 2 city to enter upon the above-mentioned property for Inspection purposes, ALTER ORADDTOMECH. MA
Date ' ReCel tic
Za!-111,111,o
tsave,IndemNfy an d keep herMen the City of Cupertino P
,jad sob,ypesn panne which treyInanywayaccrue AIR IIANDUNC UMT(f010,000SUBTOTAL:. In naptf�phce gonu^g of rob permit AIR HANDLINGIINI'['(OVER 10,[X10 CIT1Y CONSTRUCTION TAX
Signature of Applicant//CCC000nn/tractor 11 Data EXHAUST HOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZA R DOUS MATERIA LS DI SCLOSURE
Wllltheappli nt or future bulldingoecupant store or handle hazardous HEATINGUNBTOOIOD,LTI(BTU) Date RLYeI tb
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety CodZ&ction 2M32(a)7 HEATING UM'I'(OVER l00,W0 BTU) TOTAL:.Yen _ No
Will the applicanto future building occupanttaw equlpmartor devices VENTILATION FAN CSINCLE RESID) 1$P$pDAA
p�J
which emit ham Mous air contaminants as defined by the flay Arca Air
Quality Mawgcmoot Dlst cs7' BOILER-CDMPOIIPORIO,0K0BTU)
n Yes LNo
have read the hazz ous materials rcgummenb under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) (� p q 3
the California
la ealth&Safety Code,Sectlons 25505,25533 and 25534.1 AUQ 9 . ,
understa lid that the building snot arrently have.tenant,that itbmy NEW RESIDENTIAL MECH. SQ.FT
resp° ilityt notify eoc a�thco,,;I�—Ruwhichnrrasbrnxtpri° inu a o!a e of
Ownerorauthorimd agert I Date TOTAL: IS.SUFDBY:� Q�VGC
OFFICE COPY