22756 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pined Identification PERMIT NO.
Building Address: A9 E 22756
wrera me: one: -
CITY OF CUPERTINO-BUILDING DIVISION n/
• G rano s"•n•' o/oLieNo APPLICATION /PERMIT �' 7
3 BUILDIN'—..TRICAL•PLUMBING-MECHAMCAL CATEGORY CONTROL N
A,hitenglreer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address f"9/// PaPs//✓G/GIQbE Woe Ga� uv
PGRMITISSUANCE ,❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I likersed Burirovlelonsoffh..r9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith in
meandefelon3otthe Busireuand Pro(eulone Code,and my
license Is In tun tyyyyyyrce and effect. 9 33 PANELS
LlcenaLw Conp ^ K
Dale Contractor IG
UP TO 200 AMPS
ARCHITECPSDECLARATION rd C. 1•rn/G OV'ERIOA�PS SQ,Fr.FLOOR AREA
x Z I understand my plan stun be used u pubic rerorda •—���� A L E D 1
OO
Iz�ftWuj Licensed Proleviovl SIGNS ELECTRICAL
G
OWNER-BUILDER DECLARATION SPECIAL CIItCNT/MLSC I�A �� �C
erebyalflrm tOWNEeaempt ER DELAntATIOaLlcenee Law(orthe 'Vt G
7o folio Ing reason.(Section 7031.5,Business and Profeaslons Cod An c or
OZF. o ty TEMP.METER OR POLE INST. /
caun which requ(resapertNtlorovhuctftesthlmpli de hh,orrtpatr
< any at rc tate to it th Imes,licent upursuant to asuions of It e
ry1�V file a V Ratement that k h Licensed pursuant to a provisions of the DA
Owl Contractor License law(Chapter 9(mmmencing Sectln 7000)Of Dh i-
slon3ofthe sinew and Profeml..Code)mthx elseaempttherefmmarl SWIMMING POOL ELECTRIC VALUATION
6 5 the basis forth alleged exemption. Any viol on of Semon 7031.5 by any OUTLET'S.SWITCHPSEXTURES YJ
yaO appllantforape tsubjectstheapplicant advil penalty effect morethan
R flv�e,�u aso doth (g50B). NEW RESIDENTIAL ELFCTR SQ.Fr, STORIES TYPECONSTRUCTION
GG�11j 7 Q uI,es owner of t property,or employee•with wages as lhdr wile
mmpenutlon,wlldot workand estructure knot intended or offend for
❑ uh(See 7044,Bus•as it Pmf lore Code:The Contractors License Law
does not apply to an owns f perry who builds or improves thereon,and OCC.GROUP RFS.UNITS
whodoeseuch.mlihmetalt roughhhownemployeea,provldedthatsuch
Improvementsarenotinte a rof(emdfor•ale.If,however,thebulldingor TOTAL:
lmpmvementhsoldwk ore rofcompletbntheowner-bulderwillhave
the burden of provin at he did build or improve for purpose of ulej. QTy, PLUMBING PERMIT FEE FLOOD7ONE APN
EJ L as owner a e pvpeny, exclusively contracting with licensed PERMITISSUANCE
mntrectorstaro mct the P. (Se 70K Buslneuul Protauln Code:
The Contractor' Ianse Lew does nn ply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
build reo
or Int as then, and who tram for such plojem with a -
cblame
p(Ianor(a Ice needpunuanttothe Contr ori Llcenve
I . FEE'$UMMARY
BACK FLOW PROTECT.DEVICE
LI I am exempt under Sm B Sk P C for this mason
Q1 Fret np r.erq
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RFCEIT M
WORKMAN COMPENSATION DECLARATION FDnLIRES.PER TRAP S 111001,TAX Y N
❑I hereby affirm that I have a certiflale of consent m ul(-insure,or a RECEIT N
certificate of Worken'Comeevatlonlvurana or a codified copythemof(Sec. GAS CA.SYSf'FM•I INC.40UTLEIS PARK FET. y N
Policy ab C.IQ�_ 99 p� 6C 7—'1?, RECEPf p
1'oliryp OGAS EA.SYSI7M-0VER4 MAI
BUILDING DIVISION FEES
[j Caniaedcopybhereby tumty GREASE/MUSIRLWASTE INTERCEPTOR PLANCHECKFEE
d.
Certified copy h tiled with theecitlty inspection dlvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION difthe UR SEWIR-SANITARY-STORM EA.2WFF. Date Rettf t#
Qhis Ionto not be completed lthe r(Nt b(orone hundred dollary
(f10D)arless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I snot emplhat oy
an per n the wakan to bco permit issubjc ha wed, —
1 shat not employ any pen manner n u m become subject to the WATER SYSTEM/TREATING
Workeri Compenutla ws of Ca .Date PAID
O Z Applicant
ZO NOlicantO ICANT:ILaker making Certificate of Exemption, NEW RESIDENTIAL PLMB. SQ.FT. Dater Recel t#
Hehcold be subject to the Workers'Compensation provision ofthe Labor TOTAL:
N Cod, muatforthwith romply wlthauch provislOnsor this permit hall be BU
W > de revoked. FEE
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herem
byatfirthxt there is a construction lending agency for the perform TOTAL: ELECTRIC FEE 9-1
Z once of the work for c h permit Glowed(Sec.3097,Civ.C.)
V 4 Leoil Name PLUMBING FEE
IL H Lander'...... a QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I arilythat l haveread thbapplicationand mate thatthe above information
(L hI.tin la greeto gemestlywithall pt rebya;oraand county rc nmcesand gate laws PERMIT ISSUANCE
} relatin Ilding ronstmnlon,a reby authorlu repmenlativn of this p
Zcity toe upon the abovome n property for Inspection purpoen. ALTEROR ADD TO MECH.
— (We as to save,h m a d keep harmien the City of Cupertino Date ReCel t#
agal II Ij(^ 7udg,encs, M deapenees which nay In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
as st a he granting of this permit. ATR HANDLING UNIT(OVER IO,ODOCrM) CONSTRUCTION TAX
Signwreo Appu -or Data IXFTAUSTHDDD(W/DUCT) CONSTRUCTION TAX PAID:
NA7AI MAT DISCLOSURE
Will the appllaocdtpa
nt or to Ilding occupant•tort or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the C nine Municipal Code,Chapter 9.12,and the _ Date Recei t#
Healthand Safety Code Ion 2S532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL•
❑Yes No
Will the applicant or future buildingoccvpant use equipmart ordevlces VFNDLATIONFAN(SINGLE RFSID) ISSUpIa
which emit hazardous air rontandnntsas defined by the Bay Area Air BOILER
-�r]�ftl1
Quality Management Dist 1 DHI'DR 100,000 BTU)
4 Yrs us aa��
have mad the hazy ous materia quimm ntsunderChapter6.95of BOILER-COMP(OVEt 100,000 BTU) `s�'
the Calif- Health kSafetyC Ions 25505,25533 and 25534. 1
unffhtif the bull tmrmntlyhavc etenangthat ltlsmy NEW RESIDENTIAL MECH. SQ.I7.
resify a the requlremenb whichmustbecocaC.[(�Of rftrt rpra Al f0 mpancy. V L�' a
h alb
Owner or authoriseAll—
d agent Data p'
TOTAL: ISSUED -„
OFFICE COPY