22963 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address. 22963
,nv ` one: q
CITY OF CUPERTINO-BUILDING DIVISION ^� d
Confa�am : G iv ass , NAPPLICATION / PERMIT CAIFRY
Architect/Engineer. Lk.No: LDING-ELECTRICALnlIMBINCMECt1AMCAL ' COG,",
O - ` I
p r�,
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERhBTI55UANCE ��' ❑
LICI.'NSED CONTRACTOR'S DECLARATION
Thereby aHirmthat l am Ucenaed under provisions of Chapter9(comencen, APPLIANCES-RESIDENTIAL JOB DPSUB111110N,
ingwith Sectian7000)af Dlvision3oflhe Buelnesaand Pmfesalon,Code,and my
Bion ass R f rad effect. PANELS
Llren Ines Lk.4 //r►1- `\F�l ; ,^`'ol�./1
Dale Pin, ContractorUP TO 2DO AMPS
ARCHITECTS DECLARATION 201-IODO AMPS
a2 I understand my plane shall be used as public records. OVER 1000 AMPS SQ.IT FLOOR AREA $/SQ.FT.
cc
Licensed Pmfedlanal SIGNS ELECTRICAL Z�
LL OWNER-BUILDER DECLARATION
I-na SPECALCIRCIRT/MISE
7IhercressumSectiom31.5,Business fromthed Professio Wmnulaw fort he ` �
followingreason.iSectionrmit to, onertmLand Professions Code:Any T
O j,� TEMP.METEROR POLE INST.
r county which requiresapermlt tororutrvd,alters Improve,demolbh,orrepair
any stmeum prior to its Issuance,also require.the applicant for such permit to POWER DEVICES a/
14
file a tlgned statement that he Is r9(cors pursuant it the Sodium
7DOO) of the
/ 92
IS Cnn3oftheus[resLaw(Chasslonsmm)orthag eisexemptth000)ofeas
��Og slon3o(the Bueinesaand PrafediosuCode)orthat hebexemptthere(romand SWBdhfING POOL ELGCIRIC ,UATION
Q
the wads for the alleged exemption, My violation of Section 7MIS by an UTLEIBSN7'fC}iFSFIXTURES L ( I
applicant for a permit subjects theapplicant ton civil penalty of not morethan ( ^�
tiv-11.as owner
thepr). NEW RESIDENTIAL ELECTR SQYr. STOIU FS .TYPE CONSTRUCTION
❑],sue Owner of the property,or my employees with wages;as Thee Bole
.1.i5c uBon,w01 Bothe work and ionstrutlumh not intended or License
ed for
gg O die(Sec.apply
to alnan ow owner
fpropProfesdou Code:The Contractors Llreue Izw
L}�$ does net applytorkhi morph pghhlsery o emplyilds of i ,pv idedton,and OCC.GROUP RES.UNITS
0.0. whodoesauchworkMmeel(orthmugh Neownemployeea,pravlded thatmmh -
improvements are not intended or Offered forests.If,however,thebulidleg or TOI '
improvement bsold withinoneyearofcompldion,theowner-builderwill have
tlW.Iurden of proving that he did not build or Improve for purpose ofdk.), QTy. PLUMBING PERMIT FEE plppD TONE APN
u4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the pmjed(Sec.7014,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or Improves thereon, and who contracts for such ptojects with a
cga4ador(s)Bmeand pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICEFEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIITR
WORKMAN COMPENSATION DECLARATION FIXTURE4 PER TRAP SCHOOLTAX Y N
❑I hereby af(Irm that I have•rediBcate of consent to.el(•Insure,ora RECEn r M
cenlflI bo(Worken'Compewtlonlvuranre on rerilllOd ropythemof pec. CAS.EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3BOO,Feb CJ
Polity GAS.EA.SYSTEM-OVER 4(PA) RECEIPT x
ano y BUILDING DIVISION FEES
Cam
' �cerilBeacopyIsherebyfumlehed. .GREASE/INDUSIRLWASTEINTERCII'TOR ill
ECKFEE
❑Certified copy is filed with the city inspection division. ` l
CERTIFICATE OF F7(EMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SEINER-SANUARYSTORM G100FT ate emi t#
(this section need not W completed tithe permit b forone hundred dollars
($10florled.) WATER HEATER W/VEM/EL[C7R -E Y N
I certify that N the Performance ofthe week forwhich this permit is Issued, —
I shall nm employ any person in any manner m u to become subject to the WATER SYSTl7.1/TREATING
Workeu'Compensatlon Uwso(Calitomla.Date
ZZ Applicant NEW RESIDENTIAL PLMB. SQ%F. to Recef t#
O NOTicant APPLICANT:IL after making lhb Certiflmle o(Exemptlon,you
should Wrome,subject to the Workers'Compemuation pewishme of the Labor - O-FAL:
fU Code,you at fort hwlth comply with such provisions or this permitahall be
deemed revokes. FEE
LUc CONSTRUCTION LENDING AGENCY FEE
Iherebyaffirmthattherei aronstrvdionlendingagencyfortheperfomt ELECTRIC FEE
=) Z ance ofthe workforwhichthle pe rmBbexxmd(Sec.3097,Civ.CO TOTAL:
U O Lenders Name PLUMBING FEE
U. Lender'.Address QTY. MECHANICAL PERMIT FEE
U MECHANICAL FEE
I redifythat l have read thisappliaBonand antethatthe.lewetefomvtlon
O a 6correct.I agree to comply with all city and county ordinances and Axis law. PERMIT ISSUANCE FEES PAID:
relating to Wilding construction,and hereby authorize representatives of this
f-. Z atytoXllsbi
nlhe above-menifOned property for inspection purposes. ALTERORADDTOMECH. Date Reel t#
_ (Weo save,IndenWty an d keep harmlem the City of Cupertino P
,' g s,cosaandexpeosr,whlch may In any wayarerve AIR HANDLING UNIT(TO 10,000 CFM)
SUB OTAL:
ro ence o(the o(thla permit ATR HANDLING UNIT(OVER IO,(DO CFM) CONSTRUCTIONT X
ig o Alin tr r Da IXHAIISTHOOD(W/DUCT) CONSTRUCTION T C PAID:
HA2ARD
SI
MATERIALS DISCLOSURE
Will the applicant or fu re building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) DatC RC i t# '
material as defined by the Cupertino Municipal Code Chapter 9.12,and the -
Health and Safety Cade�+.in
25532(a)7 HEATING UNIT(OVER 10,0W BTU) TO I
❑Yea in No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management F)Wrid7 BOILER-COMP OHP OR 100,0(1!1 BTU) P A � p,
q We No
have readihehsza ousnuteria6rmpimm nhunderChapler6.95of BOILER-COMP 100,0DO BTU)
the G llfomb Health&Safety Code,Sections 25505,25533 and 2SS3L 1 11p�C1 � 199
understand that lithe Wre
building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FI
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate.!Occupancy. QIY
OF CUPtntuvv
Owner or authorized agent Date � ISSUED BY:-4
TOT
OFFICE COPY