22254 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Aaareas: 22254
'Lo/-too M
' 7 comers one: p
SSV Fl- CITY OF CUPERTINO-BUILDING DIVISION �A
Contract aName Lk.No: APPLICATION / PERMIT
BUILDING-ELECTRICALT'-UMBINGMECHAMCAL CATEGORY CONTROI[IPYyj
A Itect/Engineer. Lk.No: LL"�f OO���I
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PLRMITISSUANCE R.
LICF.NSF.D CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under proverims of Chapter 9(commeem APPUANCESRESIDENTTAL JOB DESCRIPTION
Ingweh Section to.and
oflhe BuslrLeasand Pro(e.lonsC-ode,andm PANELS f1/1..1 / pm' a
license Is ec full force and effect. Li eD V ",(✓
License Class Lk.11 --44
Date Contactor t V
ARCHITECI'SDECLARATION 201-IODOAMPS
ac k' 1understand my plans shagbe used nspublicrecords OVER1000AMPS SQ.F r.FLOOR AREA $/SQ.FT.
Rod IN
_ Licensed Professional SIGNSELECTRICAL
C m OWNER-BUILDER DECLARATION
Ci SPECIALCBtCUfT/MLSC
Ihereby affimL that l am exempt from the Contraoore Llan.Lawfothe
following
(Section 7071.5,Business and Professions Code:Any city or TEMP MECEIt ORPOLE IN
J,K�a'� countywhlchrequhoapermit tomrotruct,alter,Improve,demolbh,orexpiate 01 �
ya6 anystructure prior to its Wuance,also requlreatheapplicant for such permit to DATP
E C 6 U file a signed statement that he la licensed pursuant to the provisions of the POWER DEVICES
�30�O Contrsoors License Lzw(Cha 9(conurencin with Section 7000)of Divi- VALUATION
sion3oftheBusinessandProfesHsioruCWd )or,haghehexempttherefromand SNOB htiNG[OOLELEC RC
p`"i!.' the bash for the alleged exemption. Any violation of Section 70315 by any r� a
I`yr165 OUTLETSSWITCHSFIXIJRESS ' OQ(/
5� applicant fora permit exemption. Any vioatlWl f Sects of not ,5 by any
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT.7f):
S TYPECON5DtUCHON
7<
compensation,❑I,as owner of the property,or my employees with wages as their sole
will do the work and the structure la not Intended or offered for K s�,1O sale(sec.7004,Business and Pmfessions Code:The Contnoors Llanse Law6R§ does not apply to an owner of property who builds or Improves thereon,and '�w. " (pwhodoessuchworkhmxiforthrough hisman employees,provided thatsuch s a . ROUP RES.UNITS
improvements arc not Intended oroffered forsele.If,however,thebuildiag a TOTAL:
i provement essold wllMnoneyearofmmpleOon,the owner-buildsrwlll have
thrg*wfmofpmving that he did not build or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE pPN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to Concoct the project(See.70K Business and Professions Code: 1-1 CV
The Cmntraooh License Law does no apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)Wild.or Improves thereoq and who contracts, for such projects with a FEE SUMMARY
coctor(s)liamed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
M I am exempt under Sec. B k P C for this aason
OUTSIDE FLES
DRAINS FLOOR ROOF,AREA, SANITARY Y_ N_
• Owner Date - OND V RFLEIPTN
WORKMAN COMPENSATION DECLARATION �.N��T.�r SCHOOLTAK Y_ N_
F1,hereby affirm Mat I have•amlRcate of consent m seoum
ll-in ,or RECEIPT X
certificate of Workers'Compensationlrssurance ora certlfted copytheexof(Sec. GAS EA.SYSIEM-1 INCAOUTLETS PARKFIF Y N
3800,Lab C.)
PolCom n GAS EA.SYSTDA-OVER4(EA) DING DTX
BUILDINGPT VISION PEES
BCertlfied copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK PEE
❑Certl(Ied copy us filed with the city inspeetion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER -STORM EA 20OFT Date RC i t#
(This section need not be completed If the permit b for one bund red dollars -24
($IW)olc..) WATER FTEATT3t W/VENT/ELGCTR ENERGY FEE Y_ N_
I certify that In the performance of the wok forwhtch this permit I,Luued,
I shall not employ any pereon In any manner an,as to become subject to the WATER SYSTEM/TREATING
Workers Compensation La Ws Of CalRor o.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
.NOM
Z O TICE TO APPLICA :If,aher making this Certificate of Exemption,you
should become subject to the Workers'Compensation provulons of the Labor TOTAL:
F (/) Code,you nwat forthwith comply withsuch provktons orthis permit shall be �T
cc 9 deemed revoked. BUILDING 'E I /a
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE _
d G I herebyafRrmthat there la a comtruction kndingagenry,forthe perform- l 4 ELECTRIC FEE Z�
Z once of the work for which this permit la Issued(Sec.3097,Civ.C.) TOTAL: "l
0 O Lenders Name PLUMBING FEE .�
LL F Lenaera Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE Cb
U lmdifythailhavemadthbapplkationandstatethattheawveinform tion
C' W isconed.I.greetocomplywithalldtyandcoun,yord7nanceeandstatelaws PERMIT ISSUANCE [ 4CO FEES PAID:
} y relating to building construction,and hereby authorize representativesofthis
F Z chytoenterupontheabove-men,loriM Property(o pectlon purposes. ALTER OR ADD TO MECH. .� Date Receipt#
(We)agree m save,Indemnify and epi ha esti he City of Cupertino
V against liabilities,' rte and me hkh nywayattroc AIR HANDLING UNIT(TO 10,000 CIM) Qc C� SUBTOTAL:
ago int IdC n e a anon ofthl ..,a s�
n _G_ / AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
5 n rc IApp Leant/Contr Data ( IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR USMA ERIALSDISCLOSURE
I
applicantor uurebull goccupant store or handle hazardous HEATING UNIT(T0100,000 BTU) Date ReCei t#
mate definedbyth CuprAi Muntcipal Code,Cbaptsr9.12,andthe -
HeelthandSafetyCWi, 5320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
MYea No
Willtheappllant orfuturebulidingrecvpantussequipment ordeviaa VFMILATIONFAN(SINGLERFSID) ISSUANCE�IZE
which emit hazardous air contaminants as defined by the Bay Area Air ,���
Quality Marugemcmt District? BOILER-COMP(3M'OR 100,000 BTU)
Yes 1❑�No /��a
Thave read Mahazardons nutedah rcquircments nnaer Chapter 6.95 of BOILER COMP(OVEI21fD,000BN) AUQ O
the California Health k SafetyCode,Sections 25505,25533 and 255M. 1 (La r=g3ge
understand that if the building dos not currently have a tenant,that It la my NEW RESIDENTIAL MECII. SQ.FT.
responsibility to notify the occupant of the requirements which most be,nal
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date - ISSUEDB
TOTAL: CL
OFFICE COPY