22547 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuildingAddress: A ('Ze(>Ni- - 22547
wnere on
U 255- f 141 CITY OF CUPERTINO-BUILDING DIVISION
Contra Mme: ` y .Nk� APPLICATION / PERMIT Q L
AW 96S BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL x
Arehlte /Engineer. LIC.No:
, 'QTr ELECTRIC'PERMIT 'FEE�' - ','�BUILDING'P,EIiMIT INFO
Address: IV PERMITISSUANCE` s . ❑
LICENSED C NTRACTOR'S DECLARATION
I hereby af(irinthat lam licevedunder provlslooaaf Chapter9(commxrc APPLIANCESRESIEENDAL JOB DESCRI'770N
ingwith Sedion7000)of Dlvlslon3ofthe Bu.ine.and Profemi.n.Code,andmy
license le In full f and effeR. PANELS _- /�/W�`��'(" "0
License Class
j_Llex J xt 1 1 ` I`r
Dateontractor
`c ARCHITE LARATI N - - 701-I000AMPS
a OVER1000AMPS (j®Fr.I- AREA
0 7O I understand my plan shall be used v public recdrda V �l•,T
�jicensed 1'rofeaslovl SIGNS EL
LECTRICALFM
6 OWNER-BUILDER DECLARATION SPEGIALCIRCUIT/ML+C T R
Ihereby affirm thatlamexemptfromthe Cont rector.Llconse Lawforthe
following reason.(Section 70)1.5,Business and Professions Cade:An d or /
O F o city 1FMPpalr .MMTRORPOLEINST.
��� roystmdumpr orbesapermRealso quirestheapromntfw.lbh,orretto V
vr,�a any at rudurctatemeltshauancgabensed pursuant to
he t forwchpermitte POWER DEVICES
O E U file a signed statement that be b licensed pursuant it the pro7000) of the A
ISContractor's Licenseemaaw(Chapter9(rom)o,thathet mmptSectiohemfmfOlvl- SWP9MINGP )OLELECTRIC -
O the basis fo thealuandexemption.Code)orthathebeection herefromand VALUATION
the barb for the alleged exemption. Any vlolacon of Section not room
by any OUTLETSSWITCHESETXTURES 04
<� appBantfor a permit aubjMathe applicant toadvil,salty of not more than s 11 SOA ,.a
p. five hundred doll..($500). NEW RESIDENTIAL EI.GCTR IT, V
�n
F-1 1,as owner of the property,or my employees with wages as their sole- `'Q'' SCORIESS TYPECONSTIIUCTION
C compensalion,wlll dothe work,andthe structure is not intended or offered for
5 sale(Sec.7044,Business and Professions Code:The Contractes Llreve Law
Flj$$ does not apply to an owner ofproperty who builds or improves thereo ,and
CC: who doe"suchwork hlmelforthrough hisownemployees,provided that such OCC.GROUP R[S.UMCS
,h{
Improvements arenot Intended oroffered forsale.Ifthowevep thebulldingor TOTAL: aQV
Improvement Lvsold withinonerarofcompidloNtheowner-bullderwlll have
th,�Nrdenof proving that he did notbulld orlmprove for Purpose ofsakJ. QTy; ��"7. .'PLUMBING PERMIT••."ai FEE'.'• p[pODZONE - APN' -
u I,as owner of the property,am exclusively conlrading with Iireved PERMIT ISSUANCE '1
contractors to covtad the project(Sec.7044,Business and I'mfoadmes Code: U
The Cant ractorb Llave Law does not apply to an owner of property,who ALTER--DRAIN VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pLokcte with a
dContraction's 'it {' 'FEE$UMMARY,'
cgBl(aod.)licensed pursuant to the Contraor's License Law. gpCg may,,PROTECT.DEVICE
LII am exempt under Sec. B k P C.for thisreawn - OUTSI :.S
Owner DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y _ N_
Este RLCEI'I x
• WORkMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a cedlBcate of consent to self-Insure,or a FIX'NRE4 PER TRAP �, v D SCHOOL TAX Y N
certificate of Wo laces Compnvatlon Insurance ora certlfled copy thereof(See, RECEIPT#
• Moe,lab C.) GAS.EA.5YSTEM-1 INCA O(mEIS . 0 b PARK FEE Y • N
policy
RECEIPT.
ccmarn - GAS EA.SYSTEM-OVER 4(EA)
y _ BUILDING DI V ISION FE ES-
Cedilcdcopybhereby filedwfumecity - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EI(EMPTION FROM WORKERS'- GREASE TRAP URA
IPAID
COMPENSATION INSURANCE '
(Thbsectlen need not be compl Ttithe SpermitURA is forone hundred dollars SEWER-SANITARY-STORM EA.700FT. Date RCCCI t#_ _
(81 I mulifeie.) WATER HFATER W/VFNT/ELECTR ENERGY FEE Y N
]certify thatoy an Person
I.nce
he work.as
b. subject-to
ubjndit b-totheed, —
I shall not employ anm,Lawn In any manner w u to become eubjnd to the
Worken'Camps vauon Lowe of Glifomia.Data WATER SYSTEM/TREATING PAID -
C' Z Applicant
Z oNOTICE TO APPLICANT.If,after making this Certlflce0a of Exemption,you NEW RFSIDFNTIAL PLMB.__SQ.FT. Date Rail t#
fshould becomnsubject to the Workers'Camp...it..provisions ofthe Labor ,m TOTAL:
CC y Code,you must forthwith comply with such provisions orthb permit shall be BUILDING '
> deemed revoked. r p
.a O CONSTRUCTION LENDING AGENCY SEISMIC PEE +
lhen,byafflrmthattherc bar toadies Nndingagencyforlheperfor,
7 Z anceoftheworkforwhichthbper t Laaasd(Sec.3097,CIv,C.)'• TOTAL: ��QQ ELECTRIC FEE 1 0
02 Lender:Name t,.,,,..' PLUMBING FEE O
LL'~ 'Leader.Address QTY. ( �i. MECHANICAL,PERMIT i' -. ,FEE•`t MECHANICAL FEE
U I cedlfylhat l have read this. pa danand datethatthe above I forma]OR
OS bronect.I agree to comply with all dty and county mdinanceseul st mlPERMTT[SSUANCE �,Q� FEE$PAID:
} relating to building construction,and hereby authorize representatives ofthb
F Z city to enter upon the abovo-mentloeed property for WpMlon purposes. ALTER OR ADD TO MECH.
— (We) We to save,Indemath
d p hammiest the City of Cupedlno - .. Date Receipt#
3a,.iabllitles,judgesbde noes which may In enywayaccme AIR[1ANIJL(NC UMT(TO 10,000 CFM) SUBTOTAL �, VQ
id Cityie ron ene t ingofthlspertnit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
of App rant/ ontra - ^ Date 1 E%]IAUST HOOD(W/Dl1CT) a S'� CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the 5ppllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) . - Date' RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the - -
HealthandSafetyCodL.ac Ion 75537(a)7 HEATING UNIT(OVER 100,IXp BTU) TOTAL: Z,Q(�
❑ Yes ff�im-No
Will theapplianto tun,building occupant use equipment or devim VENTILATION FAN(SINGLE VFSID) IS$tATE
which emit hazardous air unt.miant.a.defined by the Bay Area Air
•
QualityManagementDistrict? BOLER-COMP OFT'OR100,0(OBTLB
. Yea Wso
havnrnia Health
a .materials requtmme5,2553under
and 255 .6.1 of BOILER-COMP(OVER 100,000 BTU)
the Califunderstand
that vlth&Safety Code,
o3 no to 075505,1.5533 o rat,that It
understand that lithe building does no room a :tenant,that itbmy NEW AESIDENTIAL MEai. SQ.FT �as-.
r.po IlByto netifythe oc to em emen swhich mustWmet , W
prion ssuay�nc��e,/e_t�pa$�C(se(�dif�icancy.
Qwnerorauthorlud ag¢nt Uat � � TOTAL: J 7 r)hISSUED BY:� 7•TN /V
OFFICE COPY