22990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Project Identification n PERMITNO.
Building Add mss:
c),020- mer Z-. b;o % 22990
neva ame: I y Phone:
o1:�AL/ Vel CITY OF CUPERTINO-BUILDING DIVISION
. ctor'sName: , Lic.No APPLICATION /PERMIT
421A'15 BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLM
Amhl a t/Frgtncer. Lk.No:
r p� ./A[��—(;��/ p � `-� QTY ELECTRIC PERMPF FEE BUILDING PERMIT INFO
Address:Id?(f S-ftl�V N KIK: ate`--S- .'V;� PFRMITISSUANCE ❑ }�. 1:1LICENSED CONTRACTOR'S DECLARATION ❑ rj]
I hereby affirm that!am Decreed under provisions olChapter 9(commme APPLIANCFSRESIDENTIAL JOB DESCRIPTION
Ing with Section 7000).(Divide.3 ofthe Businessand ProfessionsCode,and my
li 1 and effect. PANELS L"•��
leen C Lie.# RZI
/ mtncto 1 � UP TO 2Q)ANTS
—
NI 5 RATION 701"1000 AMPS
(C) 1 n / rand m srerorde� OVER1000AMPS SQ.Fr.pLOOft AREA f/SQ.FT.
L ev SIGNSELECTRICALZ.
ALEDOWNER-BUILDER DECLARATION SPECTALCIRCUIT/MISC
owingAN
I here yasormthat l am 31.5,B fromass a Contracts o License Law for the � ��
cO 9 4 following reason.(Section 70315,Business and Professions Code:My dry it q p,MEILR OR POLE INSf. M P
K� , county which mquimsa permit toconctrod,alter,improve,demolish,orrcpalr
YYap anystructure priorto its Issuance,also requlreathe applicant forsuch permit to POWEE DEVICES / N//
ry E Be,a signed statement that he is licensed pursuant to the provisions of the L
?a�G C.ntntlor'sLicense Laaw(Chapter9(commencingwith Section 7000)ofDIW- SWIMMING POOL ELECTRIC
sion3 ofthe Buainemand ProfessionsCode)orthat he is exempt therefromand
y�yd the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET&SWITCM;&FIXTURES
applicant fora permit subjedsthe applicant to a civil penalty of not room than
c five hundred delta.($50U).ppWppp��s��,9, NEW RESIDEN1lAL ELECRA �,Ff. STORIES 'TYPE CONSRRUCIION
?X, ❑enaowner wll oche wohe erty,dr my employees a tints.ith gee as fend fa
compensation,goal...a work and the sC structure rotntract esdi License
w
�O sale(Sec.70py Buslnea and Professions Cade:The Contractors License law
$� does not apply to an owner of property who builds or improves thereon,and OCC.GROUI? RES.UNITS
who doe-such work h ersafforthrough hisown employees,provided that such
Improvements are not intended oroffered for sale.It,howevcp thebuilding or TOTAL:
improvement is sold within one yearafcampleloR the owner-builder will have
th rden of proving that he did not bonder improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FL000wNE nrN
I,as owner tr the property,am exclusively contracting Ing with licensed PERMIT ISSDANCE
Tho Cdoract c.nsirod thew doe(Sec.appy Business and Profevkns Cede:
RRr GOntndp ro License Law docs not apply ct an owner.f property w who
W lids or improve Ihereory and who rontnds for each ptojem with a ALTER-DRAIN&VENT-WATER(EN
agpjfad.r(s)hoe mspursuant to the Contractor.License Law. FEE SUMMARY
LJ 1 am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.D E
DRAINSFLDORROOF, 'GOND. SAMTARY Y N_
• Owner Date R[CEIPIM
WORKMAN COMPENSATION DECLARATION
ffirm reel hereby athat 1 have a o!consent to self-insure,ora FIXTURES PER SCHOOL TAX Y_ N_
D RECEJT T I
cenificatenfWorker C.mpensationlnsurancaora rertifled copy thereof(See. GAS OQ EA.SYSTEM-1 INCA OUTLETS PARK FEE YN
3Blab C.) _
_RECEI NM
Policy 1 GAS EA.SYSTEM-OVER 6(EA)
Com any BUILDING DIVISION FEES
r5my.fred ropy lshereby fumished. GREASE/INDUSfRL WASTE INTERCEPTOR
PLANCHECK FEE
❑Certified copy Is filed with tM cityimpaction division.
CERTIFICATE OF EXEMPTION FROM WORK ER S' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANrfAAY-STORMG pOF I• Dale Recti (#
(Thissooroo need net bs completed if the permit isforom hundred dollars
(f100)orlev.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I rndifythat N the ped.rmance of the w.rk for which thi.permit i.Owed,
1 shall not employ any person In any manners°as to bemm wbjed to the WATER SYSTEM/TREATING
Warkers'Compensation Laa of California.Date PAID
O Z Applicant NEW RFS DEN ALI M8. SQFT. Date Reoei t#
ZO NOTICETO APPLICANT.If,after mW
angthls Cedificateof Exemption,you
I" N should become subject to the Workeri Compensation provisions of the Labor TOTAL:
2Code,you most forthwith comply with such provisions orthis permit shall be BUILDING FEE
> d re
LU _ deemevoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il O 1 herebyaBtrmthat there Is a constrodion kndingagency forthe perform T L ELECTRIC FEE
M Z once.(the work for which this permit Is Issued(Sec.309 a,Civ.C.) PLUMBING FEE
U O trnder'.N.nr
F Le.dee.Addresa QTY. MECHANICAL PERMIT FEE
71
CL U Icertllythat]havereadthesapplicati.nand natethattheaboveteformation MECHANICAL FEE
O W ism tocomplywlth au dty and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} IL re n o u nsteaction,and hereby authorize representative of this
to teru ntheabove-mentioned rt f ins ion se. ALTER OR ADDRO MECH.
Z y j
ee y °r P"pO Date Receipt#
V _ zga(Wth set,Ndvge,Ind ce�yaertino
cher hmay ItheC.any ay ccroe SUBTOTAL:
AIR HANDLING UNIT(TO 10,000 CFM)
against Inro en o(n n th permit.
111A,r !`� AIR HANDLING UNrr(OVE]R 10,000C III CONSTRUCTION TAX
lure.!Applk ontractorD e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO RE
Willtheapplio at orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Receipt#
tectal as defimd by the Cupenino Munidpal Code,Chapter 9.17,and the
I Iealth and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,0)0 BTU) TOTAL:
❑Yes M No
Will the applicant or future building occupant use equipment ordevice, VENTILATION FAN(SINGLERESID) ISSI�A it�„aCE�D�TE
which emit havrd°us air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP OHPOR 100,00)BTU)yea NOVhavcreadtheh�Ousortuteriabrcquirement underChaper6.95°f BOR GR-COMP OVER 100,000BTO) 18 9Rf17
the CelifcrrM Health&Safety Code,Sections 75505,25533 and 7S534.1 au 1991
understand that if the building does not currently have a tenant,that it is my NEW RESIDEMIAL MECI I. SQ.ET.
responsibility to notify the occupant of the requirements which most be cart CITY ur Cu,
prior to Issuance of a Certificate ofOrcupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY