22240 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PffiWT NO.
Building Addms: 22240
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rmr• ams: I none:
,0v0t f Vf*)v CITY OF CUPERTINO-BUILDING DIVISION / d
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Lic.No: APPLICATION / PERMIT
(fn� EPaG ( hwm O tll��0 BUILDINGELECTRICALI'!.UMBINGMECHANICAL CATEGORY CONTROL#
Arch M/ one Llc
S� QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Addrcss:'�`D � t& N^^'1 pER,ORTISSUANCE iq ❑
LICENSED CONTRA R'S DECLARATIOSI
APPLIANCES-RESIDENTIAL I hereby affirm that I am licensed under provisions of Chapter 9(commene- JOB DESCRIPTION
ingwlthSedion7000)of Dlvbion3oftheBu.inessandProfesslon.Code,andmy �s.-xy .meq \t Y�+ry
Ifcense le utylfoc&f sited. �. PANES �r-�" —n 6oei ,
License laes�? /{rr V Lie p
Datef Ins.y..,F_Contrador_ 2011000 AMPS
ARCHITECT'S DECLARATI OVER TWO AMT'S F1 R $/SQ.FT.
µQ�9Z I understand my plans shall be used as public ed .
E o Licensed Professional SIGNS ELECTRICAL ) U T E
«<< OWNBR-BUILDER DECLARATION SPECIALCIRCUIT/MISC
I hereby affirm that l am exempt from the Coniracror's Limem Law for the
FOF mrfollowing reasun.(Sedlon 7MIZ,Business and Professions Cade:Any city or TFMP.MEfQtORPOLEINSf.
2� ntych rcq
whiubesa permit tomrutmd,alter,lmprove, mo
delbh,or repair
anystmu mpriortolblsmance,al mquimatheappllcantfarsuchpermitto POWER DEVICES
ux
_47.
(Be a signed statement that he is licensed pursuant to the provisions of the
Oµ,�. Conumors Llcenselaw(Chapler9(Commencing with Section 700()of Divi- SWIMMING IK]DL ELECTRIC VALUATION
30 an3 ofthe Buslnessand Professions Code)orthat he b exempttherefomand Q
Q the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETS-SWITCHES-FIXTURES V . 00
applicant fora permit subjects the applicant to a dvil penalty of not more than
$ fwehundreddollans($500). NEW RESIDENTIAL ELECTR_SQ.FT. STOR1IS TYI'ECONSIRUCTION
2 ❑I,as owner of the property,or my employees with wages as their sole
Compensation,will do the work and the structure Is not Intended or offered for
psale(Sec.7044.Businev and Professions Code:The Contractors License Law
$ docs not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
whod...chw.rkhmmalforthrough hisown employees,providecithatsuch
bop rweemets are not intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement bsold within oneycarofcompleilon,theowner-buaderwlll have -
t1�ep�trden o(proving that hedld not build orimprove for purpose o(saled. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am evdwively Contrading with Ilndnud PEdM1TISSUANCE
Contradon to Corawd the projed(Sec.7044,Business end Professlora Code:
The Contmdori Llrenae law ticee not apply to en owner of property wM10 ALTER-DRAIN&VENT-WATER(EA)
bu0ds or Improves thereon,and who Contracts for such Inopcot with a FEE SUMMARY
c,,&1(Yaador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under S.C. B &P C for this reason '
RTC
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DRAINFLOOR,ROOF,AREA,COND. SANITARY Y N
DRAINS FLOOR Date RECEIPT#
WORKMAN COMPENSATION DECLARATION MUW:S 13ER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a cedtficete of consent to self-Inmre,or a RECEIPT#
ndrti(Icate o(Worken'Comperwtlon lruummonora cartifled Copythereof(Sec.
); a�"4 GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ jV/0I
Poliq N rl"a RIND p
�ly��Q,,000mS GI'
GA .SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
cccrtlOed Cop rnie ed. — GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECKFEE
Certified Copy Is flied with the city Ivpeahm division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Rtsmi
(Thlssection need not be completed lithe permit Is foram hundred dollars [#
-
(s1W)arlesa.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certifythat In the performance of the work forwhlch this permit Is burned,
I.hall not employ any person In any manner so as to become subjed to the WATER SYSTEM/TREATING PAID
Workers'Compensation Laws of California. Date
0 Z Applicant NEW RESIDENTIAL Pf.MB. SQF[. Date Recei ted
Z NOTICE TO APPLICANT:If, making aking this Certificate of Exemption,you
0 APPLICANT:should become subject to the Worker'Compensation provisions ofthe Labor TOTAL:
H N Code,you must forthwith Comply with such proWlons or this permit shall be BUILDING K j_ deemed revoked. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
da Thereby affirarthat
orkforwhic this
construction lending 309nryforthe perform TOTAL: ELECTRIC FEF.
2 Lender the work!orwhlch this permit It Issued(Sec.3097,Civ,CJ
(, O Lenders his - PLUMBING FEB
IL F Lemic/.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Indrtifylhat l have read thisappBcatlonand aatethatthe above information
0 W I.comed.Iagncwmco ly wlthallcityand County ordinances and pate laws PERMITISSUANCE FEES PAID:
�. 1 relating tobuildin9 t ctlon,and herebyauthodzempresentativesofthb
F Z city to enter upon the a nmentloned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to ve, Ify an d keep harmless the City of Cu Fortino Date Receipt#
U against 11 biline d at., andexpenseswhich rtayinan wayacerae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a =.atd Cl f nsequ ofthl.pe t CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
Signature Ecant o ad e — IXHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA ATERIALS DISC URE
Will plica o uBdmgocmpantstora r h.adlehar.ni.. HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as de(Ine rtlno Municipal Code,Chapter 9.13,and/he
Health and Safety on 75533(.)7 HEATING UNIT(OVER 100,000 BTU OTAB:; R
❑Ye. No
Will the applicant or utme building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE Q
which cost hzvrdous air Conta minants as defined by the Bay Area Air JUN 1 019(ll
Quality Management District? FHP OR 100,000 BTU
4YesnF�No
have read the haza9materials requiremcota rn oderCh.pt,6.95 of BOILER-COMP(OVER 100,000 BTU)
/ thezvfe.mla Health&SafetyCo ,g d1oro75505,5533and75534.1- city��
understand that ltthebuilding does not mrrently haveatcnanL that ltkmy NEW RESIDENTIAL MECH. SQS7.
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a CettlBcate of Ocaupancy.
Owner or authorlred agent Date ISSUED
TOTAL:
OFFICE COPY