22039 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:1 15
G 22039
I'latwnere este: ��J�E I 66 one:
'- CITY OF CUPERTINO-BUILDING DIVISION I� /
Contrattor'e Name: Lie NR: APPLICATION I PERMIT
>_T "T
✓?iyatAeo RA BUILDING-ELBCTRICALPLUMBING-MWMCAL CATEGORY C jIN
Architect EngP 1—lxea.. L No: (p
S 06, 6 QTY ELECTRIC PERMIT FEE BUILDING PE MIT INFO
1EMB V71:17—
Addresv: PFRMITISSUANCE - 1:1 E]LICENSED CONTRACTOR'S DECLARATION
IherebyaffbmthatlamUcensdunderprovW...of Chapler9(mmmen APPLIANCESRESIDENTUL JOB DESCRIPTION
ing with Section 7000)aof ndofect. the Buelreasand Pro(eWonsCode,end my �/� �� �
Licc..1.].luBf and dfM. � PANELS /�
Ucensc Cb Lie.N 7 q�g��o
Data Contractor
ARCHITECT'S DECLARATION 20I-1000AMP5
{Ou OZ adept d my�+�iIl�uand as public Come. OVER 1000 AMPS SQ,FT,FLOOR AREA $/SQ.FT.
�C 1 — R. Y }AA d 9GNSE L
u Licensed Professional T
< OWNER-BUILDER DECLARATION SPECIAL C N
t., Ihembyaffirmthat l amexempt from the Commences License Law for the
foRowlag reason.(Section 7031.5,Business and Professions Code:Any city or
F, cauntywhichrequlmapermlttomruMd,alter,i pmvgdemollsh,ormpair TEMP.MEI'FIi LE
�qq'' a EI anystm=mpriortoltsismance,aleomquimstheapplkantforsuchperMtlo POWER DLVI
r U file a signed statement that he is Bmnecd pursuant to the provisions of the
3 wO C cometor'a License Law(Chapter 9(commencing with Section 7000)of Divi. SWRAMING POOL C
p„ slon3ofthelkagneseand Proferkmo Code)orthat heisexcmptlherefromand �-3 VALUATION
< the beat,(.,the alleged exemption. Any ,violation of Section 70315 by any OUTLE TC %'TRPS v Q� O
applicant fore permit subjects the applicant to a civil penalty of not nnre than
It urdred dollars(S500). NEW RESID LECTR STOWES TYPE CONSTRUCTION
�n 1,as owner of the property,or my employees with wages as their sole
c naathm,wW dothe work,and thestruclure t,not Intended or offered for
0 sale eks,70K Business and Prefemfoln Code:The Cuntmctoes Liceroe law
$$ does not apply to an owner of property who builds or improves thereon,and UP RFS.UNITS
who doea such work himself or through Msown employees,provided that such
improvements am not Intended oroffered forsale.If,however,thebuilding or
Improvement baold within ormycarof completlon,the owner-bullderwill have
tllLtiurden wing that he did rout build or lmprove for purpose ofsile.). QTY PLUMBING PERMIT FEE N
Ll L as
owner of the property,am exclusively contracting with Ilmnsed PERMIT ISSUANCE
...ore to commact the projM(Sec.7044,Businm and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)Wilde or improves thereon,and who contracts for such pKojects with a
Akfator(a)licensed pursuant to the Cormactofs License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I exempt oder Sec. B&P C for this reason
Owns DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Date- RECEB'f
WOR FANG P BATION DECLAR,TIO\ N PER TRAP SCHOOLTAX Y N
[31 hereby affirm that I have a certificate of consent to selfdmFI%TITRLS
ure,or RECEB N/'
certificate of Workem'Compematlon Insurance ora comfled repythereof(Sea
3800,Lab C.) CAS F.A.SY9TEM-1 INCA OUTLETS PARK FEE Y N
Policy RECEIP1 N
GAS EA.SYSTEM-OVER 4(EA)
Com ray BUILDING DIVISION FEES
CertlBd copyb hereby(urNshd. GREASE/[NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certmed copy is filed with the city Inspection division. f
CERTIFICATE OF EXEMPTION FROM WORKERS• GRFA'SETRAP PAID 613Zp7
COMPENSATION INSURANCE SEWER.SANITARY.SORM EA.200FT. Date Reml t#2'0U7r�
(Thio section need fiat becompletd lithe permit b(Drone hundred dolbn
($100)orless) WATER IfEATERW/VENT/ELECTR ENERGY FEE Y N
I certify thatit,the person In any manner
an as to
spermit ssubjc Issued,
1 shall not employ any person f any manner n m to become subject to the WATER SYSTEM/TREATING
Worken'Campensatlon Uwe of Callfomb, Date PAID
O Z Applicant Date Recet t#
Z O NOTICETO APPLICANT:If,after nuking this Certificate of ruemptbn,you NEW RESIDENTIAL ELMS. SOFT.
should become subject to the WorkerCompensation provisions of the Labor TOTAL: .7
V9
Code,You=at forthwith comply with such pmoblose orthb permit shall be
9 deemed revoked.
BUILDINGeV
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE k
I hereby affirmthat there t,a construction lending agency for the perform. ELECTRIC.FEE
7 Z anceofthe work for kh thep colt b Issued(Sec.3097,Civ.C.) TOTAL:
U O Lender'.Name AF\ PLUMBING FEE
LL I— Lander'.Addiess QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertifythatl have read thisappllotionand gate bertha above Information
O W
1 Iscomert.I agree to comply with all cityand county ordinances and date law, PERMITISSUANCE FEES PAID:
>. W relating to building corutructlon,end Mrebyauthorlacrepresentativesofthb
I— Z city toentei he above Wned property for Inspection Purposes. ALTERORADDTOMECH. Da[C Recel t#
V _ (We) to rave,Inde 1 an d keep harmiem the City of Cupertino P
against b Eke,J.Idgmenb -and expeneeswhichmaylnanywayacaus AIR HANDLING UNIT 10,000 CPM) SUBTOTAL:
again sa City lnron-equ of the granting o(thl.Permit.
AIR HANDLING UNIT(OVER 10,000CIT1) CONSTRUCTION TAX
Sig am of Ap• t tractor at 1 EXHAUST HOOD(W/DUCT) CONSTRUCTION XPAID:
HA US MATERIALS DISCLOSURE
Will the applicant o tare building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
materials.defied by the Cupertino Municipal Coda Chapter 9.12,and the Date ece1Dt
Health and Safety Ca it,,�Fatlon 25532(a)7 HEATING UNIT(OVER I OQ000 BTU) T
Yee No
Will the applicant or!rIhm building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUAN
which emit harardous air contaminants as defined by the Bay Area Air 't)rj_
• Quality Management D�btyct7 BOILER-COMPOHPOR100,000BTLB '�'1 A.!
4 Yea f�QN0 �J
have read the hazarnSTo``us materials mclulrementsunderChapterli.95 of BOE.ER.COMP(OVER I00,DDO BTU)
the Callfornla Health&Safety Code,Settlmu 25505,2593 and 25534.1
understand that if thebullding does not currently have a tenant,that it is my NEWRFSIDENTIAL MECH. SQ.FT
ormibilitytonillythe occupant of the requirements which must be mat
o issuance Cenifi t off) Percy.
Owner or aulhoriud agent I Date ,TOTAL. ISSUED BY:
OFFICE COPY