22866 APPLICANT TO FILL IN INFORMATION-WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address as 3o R nc� d 22866
nen one:
CITY OF CUPERTINO-BUILDING DIVISION
Contra of N. LIc:No: APPLICATION / PERMIT ^-��'
BUTLDINGELECTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL M
A unct/ gloser: Llc.1,1.. 1
,Q,ry p l-, ,: LI DING RMIT O
- ''� B IL PE INF
' ' �ELECTRIC PERMIT' ' •:`� '� FEE'" '""- � •-
Address:. . ' PERMITISSUANCE _ ❑• •• ❑ �/)1 ❑
LICENSED CONTRACTOR'S DECLARATION ICI
- Ihc.byaffbm that l slicensed under provBionso(Chapter9(comm
enc, APPLIANCFSRESIDENTIAL - JOB DESCRIPTION -
ingwmithS di..7000)of Divlelon3ofthe BusinemzndProfessionsCod and my ,
lire..Is In full force nd effect. PANELS
11.n.Cl Lic.k t - -`
bats' 44; Cpntraao�--,�� � w ,
1 ARCHITECI•S DECLARATION 201-IMOAMPS
re0 ZO 1 underetaod my plain shag oe used as p Adle records. OVER I OOO AMIS SQ.FT.FLOOR AREA $/SQ.FT.
RuLicensed Professional S CNS ELECTRICAL,
OWNER-BUILDER DECLARATION SPFGIALCE(CUIT/MISC '
7 F r"Jd 3 I hemby affirm that I am exempt from the Contractors License Law for the
pp following reason.(Section 70315,Business and Pmfrasoma Code:Any city or
� i"ry caunty which requires a permit to construct,alter,improve,demolish orrcpalr TEMP.METER ORI'OLEINST.
`a 7 any structure pd.,to its issue ncG also requires theappllont forauch permit to
(its a signed statement that he Is licensed pursuant to the pewislom of the POWER DEVICES
30� Contractors Llecose Law(Chapter I(commencing with Section 7")of D'-I- SWIMMING POOL ELECTRIC
E, A sion3ofthe Businemand Prof.i..Code)arthathelae.mpttherefmmand VALUATION
the Weis for the alleged exemption. Any violation of Section 7031.5 by any
o` applicant fora permdtsubjectstheappllcantto adoll pemityofect mre
othan OUTLETS-SWITCHES-FIXTURES
n�i Eye FIL ashundred
ownerdelta.he pro NEW RESIDENTIAL ELECTR S/Q.FT. STORIED TYPE CONSTRUCTION
�n ❑Las owner of the property,or he employees with wages r theirsole
compensation,willdouseworkfocul ,Code:The
not Intended oroffendfar
- O dale(Sec.apply
Business and property
Code:The Contractors License lawdoes -
'� $ whorl nettapcby rkh[an morph pgy sowneho dsorim,po ids mon,that and
�•$^ whodoeesuch workhimsel(orthrwgh Msownemployee;provldedthetwch OCC.GROUI' RFS.UNIT
Improvementsam not Intended oroffered foreale.If,however,the build Ing or TOTAL: '
- Improvement uwldwithlnoneyearofcompletb theowner-builderwlll have
' t rde..fprovlbgthat he did notbuudorimprove for purpose of sale.). QTY, PLUMBING PERMIT ' ' ' ' .FEE" FLOODZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ap
contractors to construct the protect(Sec.7044,Business and Professions Code: a
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(FA)
builds or Improves thereon;and who contracts for such p(oject - -
s with a .. -
c7Vctoda)licensed pursuant to the Contractor's License Law. FEE SUMMARY'
1_j I am exempt under Sec. B k P C for this maven BACKFLOW PROTECT.DEVICE OUTSIDE FEES
DR.MNS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner - Date RECEIPTNB '
WORKMAN COMPENSATION DECLARATION
hedflesereby affirm that 1 have a certificate o!consent to self-Insure,or FIXTURES. TRAP SCHOOL TAX Y N
RECEIPTM
I 00,La a of Workers'Compemaupplvuranceora rerti(Icd copythereaf(Sec. GAS EA.SYSfEM-I WC.40I17LE75 - PARK PEE y N
Policy
Lab C.)_,sa,,� VX
'I'ollryp VV p.
Un m anv Ll ei AaZnS{voA S GARA.SYSTEM-OVER (E
VER4A) BWLDINGRECEDINC DI DI VISION PEE$
ertified copy V hereby tGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE .
citified copy Is filed withh the city Inspection division.the city .
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID .
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recei t#
(Thissectlon need not be completed if the permit U for one hundred dollars
($10fDorless.) _ wA'rv(HEATQ(w/VENTjELECTR ENERGYFEE Y N
Icertify that in the performance of thework forwhlch this permit is Owed, r
I sW II not employ any person In any rmnner w as to become subject to the WATER SYSTf7rf/TREATING
workers Compensation Lam of California.Data PAID
O Z Applicator NEW RESIDENTIAL PLMB. SQ.FT. Dale Revel t#
Z O NOTICE TO APPLICANT:If,after making this Certl(latc of Exem(xlon,you
should become subject to the Workers'Compensat Ion provblons of the Labor 'TOTAL:
ccCode,you at forthwith comply wlthsuch proviilons or this pcomtshall he
> deemed revoked. BUILDING ELE
a. - CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affirm that 6ers V a construction lending agency for the perform,
ELECTRIC FEE
7 Z ance ofthework for which this permit V bwed(Sec.3097,CIv.C.) TOTAL:
U O Iander.IJame PLUMBING FEE
LL h Lenders Address QTY. " MECHANICAL PERMIT!"' ' FEE ' ,MECHANICAL FEE
O W 1cert(fy that Wve read thb.ppElationand statethattheabove information
Iscorrect.I agree to comply with all city and county ordhancesand state lawn PERMIT ISSUANCE FEES PAID:
} d relating to Wilding construcuon,and hereby authorize representatives ofthis
I" city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z
VZ (We)agree to save,Ind emalfy an d keep harmless the City of Cu pert Ino - Date Receipt#
against liabilities,judgments,costs and expenses whim may In any way accrue AIR HANDLING UNIT(TO III"CFM) SUBTOTAL:
against said City in consequence of the gra ruing of this permit
AIR HANDLING UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor - - Date EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(uture building occupant storeor handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino M6cidpa l Code,Chapter 9.12,and the Date Recei t#
Plealth and Safety Code Section 25532(a)i HEATING UNIT(OVER I00,D00 BTU) TOTA rizu
❑ Yin M No
Will the applicant or future building ompant use equipment or devise V- LATION FAN(SINGLE RE5ID) ISSUANCE DATE
conift Management
air contaminants minanb as defined by the Bay Area Air ,
Quality Mawgement DisWct7 BORFRCOMP pFO'DR IOO,WO BTU)
4�° 9No
h if reads ealth& a Code, .mons 2555,2553 Chapter of BOILER-C'OMP(OVQt 100,000 BTU)
Caluhs
understand
building
Code,Sectlom25505,on a tenant,25534.I
usponsand that if he tify the occupant of t erruntlyecluft manehicherhatit[a my NEW RESIDENTIAL MECH. �.FT JAN 02 19
responsibility to notify the occupant of the requirements which muit be mM
prior to Issuance of a Certificate of Ompanry. W
Circ it, ;Uj;`�,wyu W
Owner or au(horized agent Data saae
ISSUED Ry.—
TOTAL
OFFICE COPY