22167APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bundles Protest Identification
Bulld7ny Addreaa: 1 t
PERMIT NO.
22167
ner
one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A
ConName: Lic.N.
t9 617
CATEGORY
CONTROL#
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BNLDINGELECTWCALPLUMBING-MECFIAMCAL
Asalelleet'/�sRer �% Lic. a:
'�'•iGo sedl jvaJqs-BUILDING
QTY ELECTRIC PERMIT FEE
PERMIT INFO
Address: 5ACR&MEAtrO
so El 1:1 ❑
PERMITISSUANCE
LIC ENSED CONTRACTOR'S DECLARATION
I hereby affirm that are Leensed under provWores of Chapter 9(wmmenc.
Ing with Section 7000) of Division 3 ofthe Business and ProfesslonsCode, and my
bcensa Is In (u- effect
License LIc.Y
APPLIANCES -RESIDENTIAL
r JOB DFPCRBrf70N
PANELS
Date Cantador
UPTO2
701-1000 AMPS
ARCHITECTS DB RA N
OVER 1000 AMPS
SQ. FT. FLOOR WREA $/SQ. FT.
I understand my plana shall be used as public records.
SIGNSELECTRICAL i' ' IN�
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that[am exempt fromthe Contractors License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a Perrot Weenstmd, re
alter, Improve, deolish,orrepalr
any structure prior to its issuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapler9(commencingwlth Section 7000)of Divi-
slon 3 ofthe Buslneisand Profeasbru Code) orthat he 6 exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
h
applicant fora permit subject the applicant too civil penalty of cad moretan
A II -, 'sa
n
' E R
!!!
ATIONO D
( �0 D
SI'ECULCIRCNT/M15C :
TEMP. METER OR POLE INST.
POWER DEVICESA'�
SWIMMING 100E E.ECTRIC
OUTLETSSWITCHESEXT[1RFS
NEW RESIDENTIAL ELECTR _SQ.FT.
dollars(SM.
flemployment
, as owner of the property, or my employewith wages as their sole
STORIES TYPE CONSTRUCTION
comperuadoo,windothe work and lhestrucNre 6 not Intended or offered for
.to (See. 7061, Buidne s and IYofead.. Code: The Cmurac o . License law
does not apply to an owner of property who builds or Improves thereory and
who does such work himself orthrough his own employees, provided that web
OCC.GROIIIa RES. UNITS
Improvements are not intended oroffered forsale. If, however, thebuilding or
improvement bwldwithlnaneyearofcompletiorytheowner-builderwill have
TOTAL:
t110�urden of proving that he did not build or Improve for purpose of bale.).
u L as owner of the property, am exclusively contracting with licensed
centradors to mnstmet the project (Sec. 7014, Business and Profestiora Code:
QTY. PLUMBING PERMIT FEE
FTpODZONE APN
PERMITIS,SUANCE
Tia Contmdor's License law does not apply to an owner of property who
builds or Improves thereon, and who common, for such p0okds with a
�gD7(adoKa Bcenwd pursuanttothe mundoes Llcense Law.
Lf I am exempt under Sec. B & P C for this reason
ALTER -DRAIN& VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS. FLOOR, ROOF, AREA, CONTI.-
SANITARY Y N_
RECEIPT Y
Owner Date
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that I have a certificate of consent to self -Insure, or
ceniflateof Workers'Compewhmlmumnmwamnif4 mpythe=(&c.
3800, Lab C.)
Poli #
pfxgUfgg PER TRAP
SCI{OOL TAX Y_ N_
RFLEPT Y
CAS EA. SYSTEM -1 INCA OUTLETS
PARK FFP Y N
RECEIPT #
ASA.
GESYSIET{-OVER4(EA)
Com any
BUILDING DIVISION FEES
Cedlfied copy ts hereby furnished.
Certified copy 6 filed with the city Inspection division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
T7
J �'
GREASE TRAP
CERTIFICATE OF E)(EMYTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 70OFT.
COMPENSATION INSURANCE
(This section need nd be complded If the permit 6 forom hundred dollars
($1ro)•orless.)
I certify that in the performance ofthe work forwhich this permit is Issued,
I shall not employ any person In any manner w as to berome subject to the
Workers Compensation laws of California. Date
Date Recei f#
WATER ]{EATER W/VENT/dECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant E
NOTICE TO APPLICANT: , after making this Certificate of Exemption, you
should become subject to the WorkersCompensation prov6lon ofthe Labor
Date Revel [g
NEW RESIDENTIAL PLMB. _$Q.ET.
TOTAL:
1,77 7
Code, you at forthwith comply Mth ouch provisions or this permit shall be
dremed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING FEE
OD
SEISMIC FEE
ISD
I hereby affirmthat there 6 a comtmcilon lending agency for the perform-
ance of the work for which this permit 6Issued (See. 3097, Civ. C.)
Lenders Name
Lender's Address
I cenlfythat I have rea ithisapplicatlon and statethat theaboveleformentlon
bcorred.I agree to complywith all city and county ordlnanms and nate laws
TOTAL:
ELECTRICFEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building Nrutmdiory and hereby authorlae mpresentativn of this
city to enter upon the above-mentioned property, for Inspection purposes.
(We) agree to save, IndemN(y d keep harmi<ss the Clty of Cupertino
Dale ReCCI [g
ALTER OR ADD TO MECH.
SUBTOTAL:
against llabilitln,jud mots, cost dexpenses which may In any ova acerae
agabo t i sequen f the grantingofthis perm) /y
` /�/
AIR HANDLING UNIT (TO l0,000CFM)
AIR HANDLING UNIT (OVER 10,OD0CPM)
CONSTRUCTION TAX
Ig •u pliant/Co odor ate
IXI{AUST HOOD (W/Dt1CT)
CONSTRUCTION TAX PAID:
HA2ARI OUS MATERIALS DISCLOSURE '
HEATING UNIT (TO 100,000 BTU)
Wllltheapplicant or topanbtoreorhandleha Mous
materlal as de0md by the Cupertino Municipal Code, Chapter 9.1 7, and the
Date Reaci fk
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
1�a.
+�!
Health and SafetyCode Ion 25532(a)7
VFNDLATION FAN (SINGLE RE5ID)
I�SUN d EDATE
a -aa}
RNoYee
Rlthcapplicant rfuture building occupant use equipment or devices
which et hazardous air contaminants as defined by the Bay Arca Air
mi
Qua Illy Ma nagemcnt D6 d7
Yea No
BOILER -COMP OFE' OR 100,000 BTU)
I have read the r e materials requirements under Chapter 6.95 of
1
1
BOILER -COMP (OVER 100,OW BTU)
the California Elealt &Saf Code, Sections 75505,25533 and 7553/.1
MAY e
PaAi
NEW RESIDENTIAL MECH SQ.FT
understand that if the building dues not currently have a tenant, that It is my
respomlbllitytondifyth occupant the requirements which mast be and
prior to las r cocof ccupancy.
1. x
ISS[IED BY:� �ia-• ✓ISiCC
Owner uthurf agent I Date
TOTAL:
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