22635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B.Ildl.ff Protect Identification PERMIT NO.
Building Address:
_ 22635
caner^aane: -
E� L• G - 99�-// CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT 2'2
l
Arc Itect/Engineer: LIc.Na BUILDING-ELECTRICAL PLUMBING-MDCHANICAL CA'IPCARY CONTROL N/ //0 r-;7' 19
N 3 RNu / ,•' -BUILDINGPERMIT INFO '
y QTY; ;.ELECTRIC PERMITi FEE
Address: /s�DU S✓NN7 L/8
�/ PERhETISSUANCE '�•
LICENSEDCON CTOR'S DECLARATION
Ihereby affirmthat l am licensed under provisions ofChapm19(commene- APPLIANCFS.RESIDENTIAL JO DESC ON
I.nse.in fell to. iteffeR"3of(he Byiy{Res and Prole oneCode,and my - PANELS
Licen Lc.
N
- 1j it //��/\� /
DateContractor
ARCHITECTS DECLARATION 201-1000 AMPS
pW wa0w Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR ARRE G$/SQ.Fr.
E'z j Lt...d Professional SIGNS A Z� L!J 0 2• --10
6 Ool WNER-BUILDER DECLARATION C /f
0 owing ...ffi.that l am exemptfrom the Contractor's License Law for the (x:(('j/y 4,
Z 0.. following
reason.(Section 7031.5,Business and Professions Code:Any city or TEMP. O
r I"' countywhich requlresa permit to comment,alter,Improve,demolbh,orrepalr
anystmdum Pr rWitslmame,alsorequkestheappb=tforauchpemdtto
Pa 4 file a signed statement that he is licensed pursuant to the provbPOWER DEVICESlom of the _
(Wj O Contractor's License Law(Chapter 9(commencing with Section 7000)of Dist. BN'A1MIN
aim 3 ofthe Business and Professions Code)orthat he is exempt therefrom and ^ VALUATION/
Q the heals for the alleged exemption. Anyviolationtolacivi of Section mat room
by any OUTLETS-SWITCHES-FIXTURES ,a'7 / l{
the bans fora permRed ease ption.the plicyvioation fSectienalty of70tmorethan l /vt
five hundred dollen($500): NEW RESIDENTIAL ELECTR FT.
I,as owner o(the property,or my employees with wages as their sole e"Q STORIES TYPE CONSTRUCTION
compensatlon,willdothe work,and thestructure Isnot Intended or offered for
D sale(Sec.7044,Businessend Professions Code:The Contractor's License Law _
15$ does not apply to an owner of property who builds or improves thereon,and '
EES. who dceasuch work Mmselforthr°sigh his own employees,provided that such OCC.GROUP RES UNITS
` improvements are not Intended oroffered forsale.ILhowevegthebuildingor TOTAL.
Improvementlesaidwithln oneyearofcomple11on,the owner-builderwill have
tf rurden of pausing that he did not build or Improve for purpose of sale) 'PCIJM$INGPERMIT E•:' FLOOD ZONE pPN
�I Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to consmact the project(Sec.7014,Business and Professions Code: ./
The Contractor's License Law does net apply to an owner of property who
buALTER-DRAIN kVENT-WATER
Wild, or Improves thereon, and who mntracb for such p(oj"with a
C¢Rt{acrisis)licensed pursuant to the Contractor's License Law. FEE SUMMARY
lJ I am exempt under Sac. B &P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION M RECEB'T N
❑I hereby affirm that I have a certificate of consent to self-Insure,ora FIXTURES-PER TRAP N 6/ BC tOOL TAX VR
N
certificate of Workem'Comperearlon Insurance ora certified copy thereof(Bec. RECEIPT N
3E0,Lab GAS EA.SYSTEM-I INCA OUTLETS , PARKFEE Y_ N_
Policy N - RECEIPT p
Com any GAS-EA.SYSTEM-OVER 4(EA) BUILDINGDIVISION FEES
71CertNed copy is hereby filed
.lhedthe
CREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
i Certified copy lsflled with the city iro)xctlon dlvlalon.-
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date Recei t#
(Thesection need not be completed I(the permit a(Drone hundred dollars
($100)orfyth) WATER HEATERW/VENT/ELECTR ENERGYFEE Y_ N_ -UO
Iartily thato the person
any heworkmanner fc,as
Mhos permit Is booed, (/
I ork not employ any person In any manner so u to become subject to the WATER SYSTEM/TREATING
W plicae Compensation Laws of California.Date
O Z Applicant
Z O NOTICE TO MPLICAM:IL efler making this Certl(late o(Faemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recel [#
should becomes subject to the Workem'Compensation provisions of the Labor TOTAL: it
pqg
lY N Code,you must forthwith comply with such provisions or this permit shall be UILDING FE z2•
LU j deerred revoked.
(L O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perform TOp f ELECTRIC FEE
7 Z anceofthe workforwhich this permit is Issued(Sec.3097,Civ.C.) ,
Q O Lender's Name — PLUMBING FEE �--�
LL H Lenders Address QTY: MECHANICAL PERMIT ' ". FEE MECHANICAL FEE
O W I rertifythatl have restmisapp estionand statethattheabove information
brornect.lagreetocom with all etyand county ordinances and state lam PERMIT ISSUANCE FEES PAID:
H 2 O- reetingto Idingc t ctlon,and hereby authorize representatives ofthis
cityto er Pon cab e-mmolmedpropertyforly urposes. l ALTER OR ADD TO MUCH.
V _ e)a e sa nes fy an d keep harmless t of Cupertino Date Receipt#
a Inst 11 BI ea,jud aladIRDense. le nanyway come AIR HANDLING UNIT(TO 10,000 CFM). SUBTOTAL:
ai st 1 By Basso cc the acting o It:
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig tore pliant/Comraeor are EXHAUST HOOD(W/DUCD . CONSTRUCTION TAX PAID:
HAlEARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous HFATING UNIT(TO 100,000 BN) Date Recei t#
tried as defined by the Cupertino Municipal Code,Chapter 9.12 and the.
I lealth and Safety Code Section 25532(a)7 ' - HEATING UNIT(OVER 100,000 BTU) TOT
Yea M No
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE MID) - + IE.SI�/OCE DATE
which emit bamrdous air contaminants as defined by the Bay Area Air Y F� -
1 I ty Management District? BOILER-COMP DHP OR 100,000 BTU)
1�,+f Ycs he h ❑No. 1991
Ihaveread ealth&Sfetus made,Setions2mantsunaeaChapter nd2S54. I of BOILER-COMP(OVOt1W,OWBN) 4CT 2$_
the California Health building
Code, otce e25505,ve a tand25534. I
usponsi it that tonehebuild occupant
not erreuirserve ate which
that it bey NEW RESIDENTIAL MECH. SQ.FT
n
responsibility ceofafythficate antoft ancy. errentswhichmustbemet ' Cep HI'IN
prior to issuance o(a Certlfi<ate of Ocmpanry.
Owner .orauthorized agent Date
.10 ..� ISSUED BY:`�—�� r'
OFFICE COPY