22927 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification117
/ PEILWTNO.
Building Address: � � 1 2 2^2 7
ours a me: one: G AL DDA E
CITY OF CUPERTINO-BUILDING DIVISION
Contractor'sName: W - LIc.N. APPLIC ION 1 PERMIT
BUfLDIfIG-EL TRICALPL NG-M=lI MCAL CATEGORY CO RST
Architect/Engler. Lie No:
QTY LECTRIC RMT FEE BUILDING PERMIT INFO
Address: T SSUANCE 11 ❑
LICENSED CONTRACTOR'S DECLA ION
I hereby Affirm that l am licensed under provldone hapter 9(wmmenc- LIANCFS L OB DESCRIPTION
Ingwith Section 70000of Divlm.n3ofthe Buslnessand Profession Code,and my
license is In full to.and died. ANp9 _ Gil l'L_
Llante Class LION �r 3a�
Dale Contndor
ARC hall ba d As public
RATION 1 , 7 1 SQ.Fr.FLOOR AREA S/SQ.FT.
RaO ZpO I understand my pUn shat he used u public rcrorde. �Il(\V\\Iv\ O 190 ANVS
U() Licensed Profeaaloni SEL CAL '
7 F Lu by OWNER-BUILptDER DECLARATION CIRCUIT/MLSC D A
Thereon.(hmon7O3lm from the Contractor.Lians Law fort he N
toan,tyw reason.(Section 70015,Bnlness and Professions Code:Any dty or
O s: .MErIR OR POLE INST.
F 4 countrucrum rcqub.a is ..e conM1ucthotth..p Lica de r. ch,.rrcp t
anyetmcture pd.rto its Ueuone,aho requlreatheapplicant fonu 1,perMtto POWER DEVICES
0k a signed statement that he U licensed pursuant to the provlelom of the
wG og Cantndote lkerue lcaw(Chaptat (rommenMg with Sadbn 7000)of DIW- SWIMMING POOL ELECTRIC
�0 dm,3of the Business and PrU of..I.n Cod.) he exempt therefromand ON
<� the basis for the alleged exemption. Any violation of Section 70315 by any OVILETSSWITCHESHXTIIRFS
applicant for a permit subjects the applicant to a civil penalty d net onto than
!iv dred dollen($500). NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
I, owner of the property,or my employer with wages as their sok
7a top sation,wll dothe work andthe structure U not Wended or offered for
O .1.(S..7014,Business and Profession Code:The Contractors Liaise Law
does nes apply to an owner of property who builds or improves thereon,and OCG.GRDUIs , RES.IINTTS
who doessuchwork hincelorlhrough hlsownemployen,provided that such
Improvements arc not Intended droffered forsale.If,however,Ihebulldingor TOT
Improvement Usold withlnonyearofcompldioktheowner-budderMll have
t ,den of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE . APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contradars to antrud the project(Sec.7044,Business and Profession Code:
The Contractor's Llmne Law don not apply to an owner of property who ALTER-DRAW kVENT-WATER(RA)builds or Improves thereon, and who contracts for such p(ojeds with a
cactor(s)Banend pursuant to the Contractor's License Law. FEE SUMMARY
1 am vempt under Sec B k P 75C for this reawn BACK FLOW PROTECT.DEVICE
__ OUTSIDE FEES
DRAINS FLOORROOF, SANITARY Y N
Owner Date AREA COND. RECEIPT#
WORK MAN COMPENSATION DECLARATIONsentto FIXTURES.PER TRAP SCHOOLTAX Y_ N_
(]f hereby affirm that I have•artlflcato of consent to self-Insure,ora RECEIPT#
artlflate.fWorkers'Compenwtiminuranaoraadifid.pythereof(Sec.
3800,lab Cd GAS RA.SYSTEM-11NCd OUTLETS PARK FEE Y N
Policy p GAS EA.SYSTEMAVER{(EAI RECEIPT p
Com any BUILDING DIVISION FEES
[PCertlRed copy U hereby the city GREASE/NDUSTRL WASTE INTERCEPTOR PLA�N#�.11 KFEE
�Certlfed copy I,filed with the city inspection division. SBO . s, 1
CERTIFICATE OF FXEMPrION FROM WORK ERS' GREASETRAP PAID cam
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700Ff Date —h Recel t#
(Thlswalon need nd be completed If the permit U forane hundred dollars
(5700)orfWATER HEATER W/VENT/ELECT'R ENERGY FEE Y N
lartl(y that in the performance o(thewoh forwNch this pertnlHe keued,
I shall not employ any person in any manner so as to become subject to the WATI R SYSIDN/TREATING
Workere'Compensation Laws of California.Date PAID
O Z Applicant NEWRESIDENTIALPLMB, SOFf. DatC Recel t#
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Eaemptl.n,you
should become subject to the W.rkers''Compewtlon provisloru of the Labor TOTAL:
VI Cade,you at forthwith comply wlthsuch provisions or this permit shall be U
W j deemed revoked.
W c CONSTRUCTION LENDING AGENCY SEISMIC FEE R
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
0 Z ante of the workfor which this permit U Lwed(Sec.3097,Civ.C.) TOTAL:
V O Iandar'a No. PLUMBING FEE
IL F. Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iarllfythat l have readthb applicatlonand statethattheabove Information q1 /
a Ice correct.l agree to comply with all cityand county ordinances and mate Uwe PERMITISSUANCE FEES PAID: C Y
>. N reUJng to building contrudlon,and hereby awh.rize representatives of this Y
H. Z
c
oy'o
.the above-menllonM property for Inspection purposes. ALTERORADDTOMECH. LD
Recei t#
V — save,Udam n d keep harmless the City of Cupertino P
,' gments, an pens.which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
of EP.nII gefthlspermit.
AIR HANDLING UNIT(OVER I0,00DCFM) CONSTRUCTION TAX
p cant/ bador Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARUOUSM E ALS UI. SURE
lant or future build mspant store car handle hazardous HEATING UMT(10100,fXq BTU) DRfC RCCCI t#
material as defined by the Cupe Ino Municipal Code,Chapter 9.17,and the -
He❑allYandSafetyC.de Non75532(a)7 HEATING UNIT(OVER 10X000 BTU) TOTAL.
Will tho.pplicam or Nature Wilding ocxvp..t..cqulpm.t or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemlthazardoua aircontami ntaasdeflnedbylhc Bay Area Alr �7 pp
Quality Management Istria BOILER-COMP(3HPORI00,IXq BTU) a'7 '
n Yes o
I Shave
re the hau f;nnaterlalsttlulrements under Chapter 6.95 a( EOILEIt•COMP(OVFR 100,000 JIM F 7 ^
the Cahfor iealth kSafcly e*ihobuildd
Sed1on75505,75S33and75S34. i aS
uAdrudtt currently have atenanlthat ltkmy NEW RESIDENTIAL MECH. SQ.FT.rethe requirements which must be met +Tppagcy. II Y UI' (P'UNtK�nerorauthorizDate
TOTAL: ISSUED B
OFFICE COPY