22536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PERMIT NO.
Building Address: 22536
J-r I Al- /VIPvE r7GaER D
oero ante: e. A A
12,14-AaI xi CITYOF CUPERTINO-BUILDING DIVISION Q'�Q�
CantnRors Name: Lic.NO, APPLICATION / PERMIT O
GA I D-L Y co e Ly BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATCGORY CONTROL#
Arehiteat/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ad ms: C-1 n � 2-rib PEMITISSUANCE ,(7p
LICENSED CONTRACTOR'S DECLARATION
TION
hereby affirm that l am licensed under provisions of Chapter 9Immanent APPLIANCES-RESIDENTIAL, JO fSCRIPTION I
tog with Section 70X0)of Division 3 ofthe Businmand ProfestonsCode,and my —�—/ G e-f P
nI
limes is in f tH fora and effect. / PANES
S'� a�-l Iti u 1}.
License Class Lie# �j e>Es
Date Contractor UP TO 200AMPS 157 S �
ARCHITECI•S DECLARATION 201-1000 AMPS
OZ I understand my plans shall be used as public records. OVERI"AMPS .FT.FLOOR AREA
CO ProfessionalSN
1n<(0 Lirnnscd Professional IGNS ELECTRICALRCUIT/
IRu OWNER-BUILDER DECLARATION SPECIALCI
s, , I hereby affirm that l am exempt from the Contractor's License Law for the
7dR.9 '� following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR
2F'u9 oauntywhich requima permlttocooetruct,alter,impmve,demOHah,orrepair
anystructure pdorto Its lemaance,abomqulres theapplicamfor®ch permit to /
1�1�,Ta POWER DEVICES
a E V file a signed statement that M is licensed pamoate,to the provision of the
�3n G contractors License Law(Chapter 9(commenciAO
ngwithSection7000)ofDivi- SWIMMINGOLELECIRIC VAL
g U ON
O sionofthe Business and Pedmloru Code)orthat he b excrepttherefromand
y15 3
the basis for the alleged exemption. Any violation of Section 7MIS by any 1 OUILE9 SWITCFIESEXTURES
applicant fees perentsubjectatheapplic.mtoa civil penatyofnot mmrcthan l
five hundred dollars(S500). NEW RESIDENTIAL ELECTR SQFF. —5MPjM TYPECONSTRUC'i'ION
❑1,as owner of the property,or my employees with wages as their sok
t compensation,will do the work,and the structure to not intended or offered for
5 Ct sale(Sec.7W4,BusUmaa and Po fmbre Code:The Cmdractofs Liarue law
$ docs not apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RES.UNITS
whodoessuchwork himselfor,henugh hisownemployees,provided that such q�9
Improvements are not Intended oroffered for sale.Ifhowevegthe Wildogior TOTAL: ,DD
improvement Issold within oneyearofcomplHloMtheavner-buMerwlll have
tI1s.IsnMen of proving that M did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE plppD PONE APN
"L as Owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corotroct the project(Sec.7014,Business and Profmions Code: r-AO--
The Contractor's License Law does not apply to an owner of property whopLTFR-DRAIN&VENT'-WATER(G)
Wilds or Improves thereon, and wW contrarn for such pNK�with •�gR([adenial licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &P C for this reasonOUTSIDE FEESOwner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECEIPTWORKMAN COMPENSATION DECLARATION FIX.�SPER TRAP SCITOOL TAX YN❑I hereby affirm that I have a certificate of consent to self-Insure,or aRECHR'T#certiftateOfWorken'Comperxsationisuuranceoracertlfkd copythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLETSPARK IEE Y N
' 3800,Iab C3 —
Policy M RECEIPT#
Com ny CAS EA.SYSTFM-0VE24(FA) BUILDING DIVISION FEES
Certified copy b hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recti IN
(ThlsaectlOn need not becompleted If the pemrdt b for one hundred dollars
($100)orim.) WATER HEATER w/vE-rr/E.ecTR ENERGY FEE Y_ N
rm _
I certify that In the perfoanceof the work for which this permit Is blued,
I shall not employ any person In any manner so as to Wrome subject to the WATER SYSTEM/TREATINXI
Workers'Compensationlaws of California.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ-FT. Date Reed IN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisiow of the Labor TOTAL:
CCN Code,you must forthwith comply with such provisions or this permit shall he B 1 DING FEE
W o0
deemed revoked.
W — CONSTRUCFION LENDING AGENCY SEISMIC FEE L
d I herebyaffirnthat them is a construction bndiagagency forth,perform, ••�� ELECTRIC FEE
7 Z ante ofthe workfmrwhichthis permit is WuedTOTAL:(Sec.3097,CIv.C.) ].tea•Q�
02 Lender'.Name PLUMBING FEE
LL F Lender'.Addms QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certifythatI have read this application and statmhatthe above information we
Is correct,Igrxx to comply with all city and county ordinances and state laws PERMITLSSUANCE 2.0 FEES PAID:
} M relating to bu llding corotruction,and hereby authorlu representatives of thio q Do
2 cit t entero n the abovementioned fee W i ses. AL=ORADDTOMECH. ( Date Aeceiptq
~ city
agreeto eve,indemnify an d loop h rmlm the City of Cupertino
V agaWtllabllitles,pd tat,cortsandexpenseswhichmayinanywayaccrue AIRHANDUNGUNR(TOI0,000CFM) SUBTOTAL:
aga set sat d Ci con ern of the granting of this permit
� _ AIR HANDLING IJMT(OVIIt 10,000 CI1N) CONSTRUCTION TAX
Signature of Applicant/ oon`tra�� Dote IXHAUST HOOD(W/DUCTI CONSTRUCTION TAX PAID:
HAIIAROOUS ATER IALS DI SCLOSU RE
Will the a ppliant or future building occupant store or handle ha>ardous HEATING UNIT(TO 100,000 BTU) Date Reeei til
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code Soction25532(x)T MATING UNIT(OVER 100,000 BTU) TOTAL .?O
Yes r]No VENTILATION FAN RFSID) ���gE
Willtheapplicant ha=rousaireorebcilants ample use the Bay Areuipmorn a
devices ,;0 ICleVlr DATE
which emithaaentent air contaminants ba.defined by the Bay Area Air l'MYV
Quality Management DlstrlctT BO[LER-CAMP(3IIP OR 100,000 BTU)
4Yes
havereadthe hJQNsomaterialsrequirements under Chapter 6.95of BOILER-COMP(OVER IW,000 BTU) �Utl V
nc Cal".on.Health&Safety Code,Sections 25505,25533.ed 25539. 1
understand,hatifthebulldingdoesnotcurrentlyhaveatenan,,thatitlsmy 11"WRI5IDENTIALMECH. SQ.FT. sskki�
responsibility to notify the Oavpant of the requirements which most W mrd
prior io bsuana of a Certificate ofO=pancy.
Owner or authorized agent Dale TOTAL. Z--SDISSUEDBY:�• �� ✓LJ
OFFICE COPY