22455 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
3ullding Addreas: 22455
2 I V2_ 1 OA u-e v � �
ne sure: one:.
We
irs fa/ 2ss-g j3o CITY OF CUPERTINO BUILDING DIVISION �1 I
' C " a u" N.: APPLICATION / PERMIT `
COa/S� 615 BUILDINGELECTRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL#
rcNtcct/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddmN,a ' Liy:(p. PERNITISSUANCE ❑ f�� ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DFSCRBHON
ingwlth Section 7000).!avidon3.fthe Busineeand PmfdcdmNCode,and my
license la in full fo and effect IO PAN L.5 S
Ecanx Clam - Z Lk.N .
Date Contractor UP TO2DOANTS
5 .
ARCH TTCl]Ise used
ECLARATION OVE21000AMPS - FT.FLOOR AREA S/SQ.Fr.
p0 0 6 I.naeretana my plant anau to idea as pnmm m=obs. L E D
Licensed Professional SIGNS ELECTRICAL (k n
- 114
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ML9C' „/' I B'� C '
7F, Iherebyaffirenthat l amexempt frourthe Contractor'sLlmnx law/orthe M (J C
p Q following reason.(Section 7031.5,Business and Professions Code:Any city or
F?�ty county which requires a permit to contrud,alter,improve,demolish,or repair 7TMP.MEIERORI'OLE INST.
any structure prior to its Issue ace,also requires the applimet for such permit to POWER DEVICES : `__
file a signed statement that he Is licensed pursuant to the provisions of the
�OwI" Contractor's License law ha erg(commencing Section 7000)of Divi-commencin VALUATION
n pt SWP4MING POOL ELECTRIC
sion3o(the Business Profession and Profion Code)orthat he bexempttherefromand
S the bash for the alleged exemption. AViolation of Section 7031.5,by any
Q ¢5 Any OUIIETSSWITCHESfl)(TURES
FE5 �
applicant for a permit subjects the applicant too civil penalty of not room than
p five hundred dollars($SM.
NEW RFSIDEMIIAL ELECTR SQFr. SCOWFS 7Y1'L'CONSTRUC'IION
g; am I,is owner of the property,or my employees with wages r offered
sole
for C mm(Sec.7044,Buldothe work and the structure Code:Tbn t IntendedContactor orrcense Lw
sale(does nor app4,Business and f propelon Code:The Contractors License Law
'r3$ whodoesuch toanownerofpropertywhonemporimprwndedthat and OCC.GROUP RFS.UNITS
whodoasu"h work Mmsededoroffe hisowale.If yees,pmvidedthatsuch
improvementsarenot Intended earofc ("reale.If,h ner-q Merwdingve ' TOTAL:
improvement bsold w¢hiss.neyearo(compinion,Neowner-bullderwlll have
t3 rraen.fpmving shat ne ala am b.Ra or lmpm.e for parp.,e ol.ale.). QTY. PLUMBING PERMITFEE FLOOD WNE APN
U 1,as owner of the property,am exclusively contra"'.,with Ikenud / PERMIT ISSUANCE
construct contractors to consct the pmject(Sec 7064,Business and Profession Code. 0 '
The Cou cbm.License law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER�
builds or Improves thereon,and who contracts for such pPjects with a '
do a)limned pursuant to the Contractor's License Law. FEE SUMMARY
='1_II am exempt under S -B&P C for this mason BACKFLOW PROTECT.DEVICE
ec
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N�
46 Owner Dns _
RECEIPT N .JL J
WORK MAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
01 hereby affirm that I have a certl0ote o!consent to self-Insure,ora � RECEB'i'X
ce'ElcateotWorkern Compensation Insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE �Y � N
MW Lab C.) —
P.Bi N1�27 r GAS EA.5YSTFM-OVFR4(FA) BUILDING
Cam any�bJo r BUILDING DIVISION FEES
[]CcrtNedmpylsherebyfumished. GREASE/INDUSTRL WA9M INTER CEPTOR. PLANCHECR FEE
C`cZed copy Is filed with the city inspection division
CERTIFICATEOFE(EMPr10NFROMWORKERS' GREASETRAP PAID
COMPENSATION INSURANCE / SEWER-SANTfARY-STORM EA.200Fr. s Op Dale Recti tN
x
(fhisctcut need not be completed if the permit b corona hundred dollars
(S10eceless') - WATER HFATERW/VENT/ELFGTR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit is Issued,
I shall not employ an7 person I.any manner x as to become subject to the WATER SYS"fEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Appliont NEW RESIDENTIAL PLMB. SQ17. Date RCCCI tq
Z O NOTICE TO APPLICANT.ILaBer making this Cert'lote.f Exemption,you
should become subject to the Workers'Compdsv tkm provision of the Labor TOTAL:
-�)
Code,you=at forthwith comply with such provision or this permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby a(Rrrnthzt them is a contraction lending agency for the perform- TOTAL: .•7 ELECTRIC FEE
7 Z an of the work forwhkhthb permit b baved(Sec.309-/,CIv.C.) /,OD
(.) o
Lender's Name - PLUMBING FEE /?olio
LL F Landersaadeass - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ImAifythatlhavemadthbappbmtbnandstatethatlheabove3 formnion
EL Is correct.I agree to comply with all city and many ordinance and state laws PERMIT ISSUANCE FEES PAID:
�. relating to building construction,and hereby authorize representatives of this
it to enter the above-mentioned forW ion 'ALTER OR ADDTO MECH. Date Reeeiptq
Z city Eon Property the
purposes.
(We)agree to save,Indemnify an d keep harmless the Clty of Cupertino V AIR HANDLING UNIT(TO le,"CFM)again abllitlee,jutlgmenb,costsand expenses which may In anyway accrue SUBTOTAL:
a s .aid City i" sryuence of the granting ofthis permit -
p. / p/ AIR HANDLING tm'IT(OVER lB,000crM) CONSTRUCTION TAX
• f O /
tum Applka vc. ;ar Data EXHAuSTHODD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
_
Will the apph.nt or future building cccupi.tstme or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rei:6 lit
mxterbl as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: /7.oD
nYes M No
Wllltheappliont or future building ocmpant useequlpment ordevices VENDLATION FAN(SINGLE RESID) IS4EDATE
'which emit havardous air contaminants as defined by the Bay Area Air
. Quality Management District?' BOILER-COMP OHPOR 100,000 BTU)
Yes ❑N"
Thave read the h dou material,requirements underChapter6.95of BOILER-COMP(OVER 100,000BTU) rrP7 x 7pL7�
the California Health&Safety Code,Sectioro 25505,75533 and 25534. I ,-
understandthatif the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. ' SQ.Fr. /Ma.
responsibility to notify the occupant of the mqulmmems which must be met jaw IIF
prior to Issuance of a Certificate of Occupancy. Gal Q�#�
Ownerorauthorized agent Data TOTAL:. ISSUED ly,,! I/ r/
OFFICE COPY