22562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Belldpla Pra ea Identification PERMIT NO.
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10 '(6 Av. av
neva ante: ET�� q18) nne
MQP fJn 7{�ct�kjLQ36 � CITY OF CUPERTINO-BUILDINGDIVISION � / qAL
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' ` ams Name Lie.No: APPLICATION l PERMIT �S O —
qr BUILDINGELECTRICALPLUMBINGMECHAMCAL C/s't ' xy CON'RROjeM'
CCS) n
Aahitect/Engineer. Lie No: IIOO
• oN QrY ELECTRIC PERMFEG BUILDING PERMIT INFO
Add.951 w p.p((F G
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provision of Chapter 9(mmmene APPLIAN RE L JOB DESCRB''fiQN
Ingwith SeRion70Xoff Dlvialon3 ofthe Businesaand PrefesalovCode,and my DT
license la In full hand effect. Pp V' tP
LlanaLic.p r
�w
Date Contractor
ARCHITF.CI'S DECLARATION 201.1000 AMPS
q�+0O CZp [understand my piawshall be used as publlcrerorde, OVER 1000 AMPS SQ FT.FLOOR AREA 51�,
Fd Licensed Profenlowl `/\ ECNSELECTIUCAL
FEryu
OWNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC
[hereby alnrmthction7 exempt dPmf.iContradonLicenseCd.Lawfothe t �^
foaowingmuon(&n10 Permit
Buelneaand PmfenlonsCode: 1sotlryor �. 'Z�fJJ G -GVH
gB cauntywhlch riortosspermit tommtequimatheapmvent forstah,ormitt SMP'METER OR POLE INST. I [
s any structure statement
its that
he
also homes ulrcathant to antfasuions of It e
0 V file a signed statement that he Is Ilreneed pursuant to the provisions of the ['OWER DEVICES
3 ee Contnnorb Liceve Law(Chapter 9(amrtancing with Section 7000)of Dlvi- J g
X01' sion3 ofthe Business and ProfenlosCode)orthat he t exempt themfmmand SWIMMING IrIOL E.ECTRIC VALU
Qthe basis for the alleged exemption. Any violation of Seniors 7631,5 by any
rethan OUTLETSSW/TCHESHKMRES
applicant for a permlt aebjena the applicant to a civil penalty of nes nit
°�� nve hnnarcd aemra(ssam.
�1,ea owner o(the property,or my employees with wages as thelrsole NEW RESIDENTIAL ELECTR_SQ,FT, STpRIFS TYPECONSTRIICTION
C>¢ rompensatlon,willdothe work endlhesWdurc Isnot intended or offered for �� O
$ O elle(Sec 7064,Business and Prof slora Code:The Contnnora Llceme Law
5$ docs not apply to an ownerofpropertywho builds orlmprovnehereoq and
who doeaeuchworkhinselforthrough hleawnemployees,provided thesuch OCC.GROUP RESUNITS
Improvement are not Intended aro(fered for sale.If,howeveq
Winger A
improvement Is sold within emyearofcompinlon,the owner-bu0der wRl have
tf�,�urden o(pmving that he did nes build or4npmve for purposeofule.). QTy, PLUMBING PERMIT FEE
u I,as owner of the property,am exduelvely contracting with licensed FLOOU-LONE APN
PCRMITISSUANCE
Conlarntoes LWctthe project(Sec,7614,Buelneas and Pro(evWro Code:
The
The Comctore License law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such iak jens with a ALTER-DRAIN&VENT-WATER(EA)
c actor(.)licensed pursuant to the Contractors Lt...Law. -FEESUMMARY
I am exempt under Sec. B&P C for this on BACK FLOW PROTECT.DEVICE
' OUTSIDF FEES
Owner Date DRAINS FLOOR F GOND, SANTTARY Y N_
Ir WORKMAN COMPENSATION DECLARATION RECEIPT#
❑I hereby affirm that I have a ceninote of09' consent to sell-Insure,or a
FIX'IVRFS PER '7 '�I , d LTA% Y N
,anisate of Worken'Comperuatlon Imurana or'adifhd copythennf(Ea. RECEI'f#
a ,
3800,LabC.) CAS-EA.SY -tI �.40 �.., I h FEES Y_ N
1'olkyp / RECLIIPT#
Company GAS EA.SYSITM-OVERI(FA) s.e
I ICertlfled copy t hereby furnished. BUILDING DIVISION FEES
rL�-J Can'tledcopytnled wnhthe city Inspection division. CRPASE/MDUSCIt �ASTfi 1NTF PLANCHECKFEE q?b.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP -
COMPENSATION INSURANCE PAID -_
(fhlsseethm.ced not becompleted lfthe permit Isforone hundred dollars SEWER-SANITARY-STORM EA.MPT. Date Rccel t#
(5100)ver Ism.)
I artily that to the performance of the work for which this permit Is Issued, WATER HEATER W/VENT/E,ECTR ENERGYPEE Y_ N_ �I�•r-n
I shall not employ any person In any manner an as to become subkct to the .l V
Workers'Compensation Lawsof Callfomt. Date WATERSYSTEM/TREATING
Z Applicant _ PAID
O NOUCETOAPPLICANT:Iftafter making thIs Certlflate o(Exemptlon,you NEW RESIDENTIAL PLMB.__SQ,FF, Daft Rett't t#'
shoutdbecamesubject to the Workers'Compensatlonprovlalmuofthe Labor TO 7V
N Code,youmustforlbwith rompiywith such provislossorthis permit shall be
darned invoked. D DIN •E 1 D
CONSTRUCTION LENDING AGENCY SEISMIC F E _ s
z lherebyafflrmthst there Is.ronetruction lending agency forthe perform ELECTRI FEE
once of the work for which this permit Is Issued(Sec 3097,Civ.C.) (�At 0 Lenders Name • PLUMDI FEE
H Lender'spthatl QTY. MECHANICAL PERMIT FEE
U Iredltythatl havercadthIs application and Yalethattheabove Information MECHA CAL FEE
1 IscornxT.I agree to comply with all cityand countyordlnancesand state laws PERMIT ISSUANCE AI
W relating to building mmtmctlan,and hereby autharlu reprcsantativca o(tht - #
z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino ReeeipH#
against liabilities,Judgment,"Band expect which may In anyway saxes AIR HANDLING UNIT(TO 10,"CFM)
age lmbald City In consequence of thegr, ng of this permit. SUBTOTAL•
1-11-79 AIR HANDLING UNIT(OVER 10,000CFM) NSTRU ION TAX
wturcofA ontractor Date EXHAUST HOOD(W/DUCTS CONSTRU ION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU,
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Rece1 t#
I lealth and Safety Cade Sectloo2 32(ap HEATING UNIT(OVER 100,000 BTUs TOTAL
❑ Yi thea N No
Wlle applicant ofuturebelldingoaupantuaeequipment ordevices VENTILATION FAN(SINGLE 1E )
which emit hazardous air eentamlrant as dermad by the Bay Area Air ISSUANCE DATE
WQu Ilty Management District? BOILER-COMP PHP OR 100,000 BM rs.s
4Yen �aI No �i
havemad the haral)usmaterials requlrementunder Cha pter695of BOILER-COMP(OVER 100,00)BTU)
Health&SafetyCode,SecUmu25565,25533and25534. I
tand that lithe building does not currently have a tenant,that It is my NEWRFSIDENTIALMECH. SQ.FTalBllityto natty the o<cv pant of the requirement which must be rrct IssuanceofaCcrtlBateofOcapancy.or authorized agent Date
- I 155IlEU BY:
4" I
OFFICE COPY