22075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERM NO.
Building Address: _ 22075
'I/"IO
ora ante: NIPh ;
CITY OF CUPERTINO 6UILDING DIVISION• yyp F APPLICATION / PERMIT( S. ' , I a TS r BUILDING—aECTRICALPLIP.s4BINGMECFIANICAL CA RY CONTROL N
Arehfted/Englacer. :
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE ❑ ❑ r ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under p.W.,,f Chapter 9(canuanc APPLIANCES-RESIDENTIAL JOB DPSCM-HON
Ingwilh Sedion7 )of Davision3ofthe Buslnemand ProfesslonsCode,and my
liccnx Isamu o 4effect PANELS .
License lass Lie
Date Contractor% C hh(lt �� ( aL
ARCHITECTS DECLARATION J mi-l"AMPS
�Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fx.FLOORARFA S/SQ.FT.
ww OSIGNS ELECTRICAL
Llcans d Professional
OWNER-BUILDER DECLARATION SPRCIALCIRCUIT/MLSC
k, Iherebyafflrmthatlamexempt from the CmaraRor'e License law for the -
pp following maine.(Sedi,n 7NIT Business and Prefesioa Code:Any city or
TEMP.METER OR POLE INST.
M countywhlchrequ4 aperMttocomtrdalter,Unpmve,demolfsh,ormpalr
.a anystrucwre prbrto Its Lcusance,also nequlresthe applicantforsuch permit to POWER DEVICES
C.V file a signed statement that he la licensed pursuant to the provisions of the
Contractor's License Law(Cha(Chapter with Section 7000)of Divi-
O cc R SWIMMING IDOL ELECTRIC
5M the
3os he Business ed exemption. Any otthat lation f exempt therefrom and 1 0 V LUA Oy-t
G Z the basis for the alleged exemption. Any violation of Semon not m re any OUILETSSWITCHFSHXTURFS (/
five hundred dollars subjadsthe appgcanttoadWl penaltyof not morethan
Ove hundred dollars he pr.
�I,as owner of the property,or rtry employees with wages as their sole NEW RESIDENTIAL ELECTS! SQFf. ST E5 TYTE GDNSDtUGTIDN
compensatlon,willdothe work,and thestructure is not Intended or offered for .
psale(Sec.7046,Bus(neu and Prdessioa Code:The CoNratl,fa Llceae Isw
$ does nal apply to an owner of property who builds or improves thereat,and IOL' RES.UNRS
C- who daesauch work himself,rthmagh hiaown employee,provided that such
Improvements are rot Intended or offered for sale.If,however,the be llding or TOTAL:
i provementhsoldwithlnoneyearofcompletion,theowner-builderwillhave
the burden of proving that he dui net build or improve for purpose ofaaleJ. QTY. PLUMBING PERMIT FEE. NE - APN
C]L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER CEM
Wilds or Improves theme.,sad who contracts for such ptojeds with a
Off,
hceaCd paracent to the Contractor's Ll...Law. FEE SUMMARY
U 1 am exempt under Sec B& P C for this reason BACK flAW PROTECT.DEVICE
QUT91 QF FEES
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_ -
RECET T N
WORKMAN COMPENSATION DECLARATION FNTURFS PER TRAP SCHOOL TAX Y_ N_
r •, �I hereby affirm that I have a certificate of consent to sel6lnsure,or a RF-CEIPT N
ceddicate,of Workers Compematlon Insurance ora motified copy thereofl5ec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
3�9$ 90
-- --urif GAS EA.SVSITM-OVER4 MA) Tp
Cenifiea copybhereby famished. BUILDING
DIVISION PGCS
Codified mpyu(Iled with the city inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR' PLANCHECK PEE
4 CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE• SEWER-SAMT.ARY-STORM EA 21017 Date Rec:ei t#
(rMasea lo"necd not be completed lithe permit is for one hundred dollars
act (510 l
Imittdlfyththat In the pedomunceof the work(orwNwWATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_ch this permit is lsed, r
I shall not employ any person in any manner so as to became subject to the WATUR SYSTEM/MRGTTNG
Workers Compensation Lwa of C.I f.rw.Data
PAID
OZ Appllcant— NEW RESIDENTIAL PLMB. SQFr. Date Rewi t#
Z O NOTICE TO APPLICANT:U,after raking this Certificate of Exemption,you
should become aubjed to the Workers Compensztton pmvlsloa of the Labor TOTAL:
N Cade,you most forthwith comply with such provision or this permit shall be BUILDING -
EE
deemed revoked.
W E3 CONSTRUCTION LENDING AGENCY SEISMIC PEE
d ST
O I hembyaffirmthat there la a construction lendingagency forthe perform TOTAL: ELECTRIC FEE
= Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
02 Lender's Name
LL t— Leaders Address. QTY. MECHANICAL PERMIT FEE, MECHANICAL FEE
OW Iced lfy that l have read this application and gate that the above Information
1 is l agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID: '
relating tobuilding construction,and hereby authorize reprexntatives of this
Z it to entero the above-mentioned forW ion s ALTER OR ADDTOMECH., Date RCCCIPt#
F" N city P°" property he
purpose. _
(We7 agree m nave,Indemnify and keep harmless the City ty .y.cems „ MR HANDLING UNIT(TO 10,000 CRU
L.I against liabilities. men's,cogaand expenses which nvyl anywayattme SUBTOTAL:
nag ts�id City I. gra u. this pe CONSTRUCTION TAX
AIR HANDLING I1hTf(OVER 10,000CFM) J1..
m of Applicant/Contractor k
Dam EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER IALS DI SCLOS RE '
Will the ppH.at orfnture building ottvpart store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cu pagan,Municipal l Cale,Chapter 9.1 Z and the -
IlalthandSafety Code Section 25532(a)7 HEATING UNIT(OVER 100,001 BTL TOTAL: ]r
O Yo r]No -
Willtheapplicantorfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air PAID '
Quality Management Distridi r BOILFR00 RTL PAID
OR 100,0 _
4Yes 171 No
haveneed the harar7ousmaterials requirements under Chapter 6kof BOILER-COMP(OVER 100,001 BTU) ��� �MCNR�
the California Health&Safety Code,Sections 25505,25533 and 25536. I _ .
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT.
responsibility to notify the occupant of the requirements which must be root
prior to issuance of a Certificate of Occupancy. CU �46
Owner or authorized agent Date 'TOTAL: ISSUED BY:\Ic"yGL
OFFICE COPY