22739 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Pra ect Identification - PERMIT NO.
Building Ad-7 1 -k _ 22739
nen ante: one: p
CITY OF CUPERTINO-BUILDING DIVISION
�Wtre °N°nom L<. APPLICATION / PERMIT ( L
• ✓I Viu.� '7 BUILDINGELECTRICAL-PLUMBINGMFGHAMCAL CATEGORY CONTROL
Architect/Engineer. f Lic.Nn
_ ?—Ty
FEE BUILDING PERMITINFO
Addrcas:1 S �Lf r',e Q Q PERMITISSUANCE . ❑ ❑ fel ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirmthat l am homaed under provisions of Chapler9(comerme. APPLIANCES-RESIDENTIALwith JOBD• HIIPIION
InenseI !.fall 7IND)ofd effeon3 oflhe Bull ncesand ProfesslonsCode,and my 1 . '��
license is In full force and d(ett. i PANELS W
Line nsefts� Lep tgSan
9
Data Contactor fFtlMA21-10 UP TO 200 AMM
201-I DJ(IAMI'5 l/- (7J1� ��
ARCHITECPS DECLARATION
OZO I understand my plans shall be used as public monis OVER1030AMPS - SQ.FT. OOR AREA S/SQ.FT.
19 LicensedProlesslonal SIGNSELECTRICAL A L E6 I-
tC� OWNER-BUILDER theC elAT10N M P U T E
t`n SPECIALCIRCUIT/MISC
7F, owing...(hction7 cemptfiness, Contractors LicenseLawfor dry or '
following reawn.(Section 70115,Busker and Professions Code:Any airy it
FIpppppp"'�+ oauntywM1lch requlresa permit toarubuat,alter,Improve,demol.M1,or repair IEMP.METER OR POLE!NST.
gO .a anystructure prior to Its Wuance,alsorequim the appliantforsuch permit to POWER DEVICES - OAT,f5 fill a signed statement the,he Is licensed Fulcrum,to the provisions of the
PQj u,� Contractor's License Law(Chapter 9(commencing with Section 7000)of Diet. SWIMMING POOL ELECTRIC� VALUATION Og- An.3aftheBusineciand ProfeseloruCode)orthat he.exempt lherefromand
6 the lana.for the alleged exemption. Any violation of Sectkn 70115 by any OfIII.ETSSWITC}[ESFIXf IJRES
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). t
❑I,as owner of the property,or my employees with wage as their sok NEW RESIDENTIAL:ELECTR SQ,Ff. STORIES TYPE CONSTRUCTION
7a compensation,will do the work and the structure is not intended or offered for
ee
q .1.(S7044,Business and Profession Code:The Contracts/.License Law
3 does not apply to an owner of property who Wilds or improves thereon,and 00C.CROUP RES.UNITS
.who does such work himself or through hisown employees,provided that well
Improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement.aold withinomyearofeomplelon,theowner-builderwUI have
tIt;,Iztrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APNr
u L as owner of the property,am exclusively contracting with hassed PERMIT ISSUANCE contractors to on.tract the project(Sce.7614 Business and Professio®Code:
The Cont-emeB License Law does not apply to an owner of property who pLTFR-DRAIN&VEM-WATER(FA)
Wilds or Improval thereon,and who contain for such pkajeets with a -
actor(s)licensed pursuant to the Commences License Law. FEE SUMMARY
ryBp
I am exempt under Sec. - B&P C for this reason BACK FLOW PROTECT.DEVICE Of Tycl lip rl:rq
Owner DRAINS ROOIL ROOF,AREA,COND.
SANITARY Y N—
. Dale RECEIPT p
W0ffi:1 Ihave SATION DECLARATION FIKTURESPERTR P SCHOOL TAX Y N
ereby affirm that I have a AlRate of consent to self-Insure,or a RECEIPT p
ce i/lcate of Workera'Compematlue Insurance ora certified copythercof(See.
3800Lab GAS EA.SYSTGI.I 7NC.40[1TLL75 PARK FEE V N
, CJ
Pollryp_(� �-Z M
CAS EA.SYSTEM-OVER d(EA)
Com any L [ —� BUILDINGDING DIVISION FEES
Cert copy.herebyfurnished. CREASE/INDUSTRLWASTR INTERCEPTOR PLANCHECK FEE
rtlfied copy filed wwith the city Inspection division. ,
CERTIFICATE OF E)(Ov[FTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE
(I'hlasectionneed not becomml
pleted ifthepert.foronehundreddollan SEWFRSANITARY-
STORM EA.2007. Data ' Receipt#
(8100)carless.) - WATERHEATEBW/vENT/aruiz ENERGY FEE' Y N-
I urtilyll not that In say Pehe omunan the war an as tobeco become
of balto ed,the '— N—
I shall not employ an/Person In any manner n as m became eubjett to the WATER SYSIPM/TREATING
Worker Compensation Laws of GB(ornk. Data PAID
0 Z Appllant NEW RESIDENTIAL PLMB. D
,Z O NOTICE TO APPLICANT:!Laher making this Certtfcate of Exempth. ,you —SQ.R. ate Repel t#
should became subject to the Workers'Comperuatlon prov.km of the Labor TOTAL:
CCN Code,you must forthwith comply withauch provisions orthis pemNtxhali be
> deemed revoked. BUILDING
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(flrmthat there is a constmction lending agency for the perform- ELECTRIC FEE
Z ance of the work!or which this permit is Issued(Sec.3097,Civ.C.) TOTAL: ,� .'�
(� O Lender.Name PLUMBING FEE'
LL H Lenders Address Q'fY. . MECHANICAL PERMIT !-E MECHANICAL FBG
.correct.I agree to complywlth all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. in
relating to building construction,and herebyauthortearepresentativesofthis
F enWM
city to enter upon the above-mentioned property for pkn purposea. ALTERORADDTOMECH. Date RCCCI t#
(We)agree to save,IndemNty an d ep Famdess the City of Cupertiw P
ZSK1kpIIc&4W=
es,jldgments,wetsan z .which may In an wya c AIR HANDLING UNIT(TO 10,OW CFM) SUBTOTAL:
y In hlfpeAIR HANDWNC UNIT(OVER 10,ODOCFM) CONSTRUCTION TAX
pt/Cont actor - I ate E)(FIAIJST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE '
Will the appllcantorfumrc hulldingompantsmrc or handle havrdous HEATING UNIT(TO l00,f100 BTU)
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Date .RCCCI t#
Iicalthand Safely Cadcr�� l°''25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ya UN.
Will the$pplicant or(uturcW ldingompan/u°e equipment or devices VENTILATION FAN(SINGLE RESID) I$gJ I/�i�(�DATE
which emit hazrrdous aUm runtsu defined by the Bay Area Air - eCr�//�11t/
Q.ralltyMarugcmont Dis I BOILER-COMP OHPOR 100,000 BTU)
4YaNo �rsaa�
have read the haze pus materials mqulrement°under Chapter 6.95 of BOILER-COMP(OV[R 1W,000 BTU) eD ly3sz�l
the Cal lfornklialth&SofetyCode,Seoi.o °25505,25533and2S534. I': 'SFr J
.ad,ptq that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
ruib'dy to notify thecae ant pit i menta which must cu
or to sofa CertiBc (Oc pn / Qf,�( 1uP
i
Uv .r r get a e ISSUED d ✓
TOTAL:
OFFICE COPY
a