22266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Addrea,: . . 22266
OS�o A Jer9ka
wren ante: one: APPLICA nON SUBMirIAL
V T j CITY OF CUPERTINO-BUILDING DIVISION P ��ILL�
cur.Name: L+."°: APPLICATION / PERMIT C
GN B BUILDINGELGCTRlCA4PL[)AfBINGMECk1ANICAl CATEGORY CONTglL
AnhImot/Eng+ver. / Lie.No: ((eek) VV
'QTY i ELECTRICPERMIT '`' FEE BUILDING PERMIT INFO -
Addressi e 'A'*A 7N/. PERMITISSUANCE - 66
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 immanent, APPILIANCESRESIDENTIAL JOB DFSCRIITION
InenseISection force anDlWfect. (the Buslneuandl'rafnelovCode,and my
lienee lain full(ora and effect. PANELS
Licene ClastLIc.N
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
q�q�vu OM I understand my plarushall be used an public records IOVERIWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
hi d Licensed Professional SIGNSELECTRICAL C") S jl ( �'L xq
errs 6 OWNER-BUILDER DECLARATION SPLCIAL T I •] ,,.qT,, f `�
F, � I hereby afRrmthal l am exempt from the Contractor's Linnse Law for the � � - o ei2 /Il (•`•�
zoo foolmeing....(Section 70115.Be,(..and Professions Code:An ct or • t'• - J """LL
OZF..� Y tY TEMP.M ;OR POLE)NSR'. '
Py countywhlch requlresa Issuanromvtruct,alter,impmvgt forsueh,ormit to
8 any structure st.t rtoimbat he Is also sed pursuanhe t
to the mvi jhpermit e I
d POWER D ICE(f,•�� !I U
U floc a signed statement that het licensed pursuant to the provisions of the
Owl Contract ors License lww(Chapter9(com)or that
with Section sfofDlvl-
'30 slon3of the Business and Pro(esslav Code)orthat he It exempt therefromand SWPIh9NC` ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70115 by any
applicantm
for a permit subjects the applicant to a civil penally of not ore than OUTLEISSWITCHESFIXTURE5 ` 1 las L-l.J
O five hundred dollars(5500). -
NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole c"Q'FT• STOW ES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for V a b
q sale(Sec 7044,Basins.and Professions Code:The Contractors License Law C
$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROIIIP RES.UNITS
whodou such work hbveUorthr°ugh his own employees,provided that such C^
Improvements are not Intended moffercd for sale.If,however,thebullding or TOTA l
Improvement lssoldwithln oneyearofcomplel Ntheowner-budderwlll have
+Iq.kurden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT + %FEE FLOOp w NNE APN
U 1,as owner of the property,am exclusively contracting with licensed
controdam to construct the project(Se 7044,B.Mores and Profession Code: PERMIT ISSUANCE
The Contractor's Licerse Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or improves thereon,and who contracts for such ptojeces with a
dnnt
oes,licensed puoutt to the Coractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B &P C for this reason
Owner Date
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y NN
-
WORKRECEIPT MAN COMPENSATION DECLARATION FI)HURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificatedoom m consent to opy three ora RECEIPT N
3S0%certifiabC.)te rken'Compensatlonlvunnce as certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3Blic IabC.)
IC-aollgN _ GAS EA.SYSTEM-OVERC(EM RECEIPT#
Y BUILDING DIVISION FRES
rtifled copy 6 filed hereby
the citer.y
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
CertNed copy V filed with the tlty Iv)xctlon division.
CERTIFICATE OF EXEM ITION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A. 00177 Date
(This section need not be completed B the permit is forces hundred dollars Receiptt 7t
(5100)°`ons') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers on Compevat+ Laws of Callfm.bt. Date PAID
OZ Applicant
Z O NOTICE TO APPLICANT:H
,after making l his Certificate of Exemption,you NEW RE9DENRMB.MB. SQFr. Date Recel HI
should become subject to the Workers'Compensation provisions of the Labor IOTA
LUU2 Code,you most forthwith comply with such provielons or this permit shall be
> deemed revoked. BU NG •' r
aCONSTRUCTIONLENDINGAGENCY SEISMIC FEE orf)
Z Iherebyafftrm that there is a construction lending agency for the perform TOTAL ELECTRIC FEE s 0®14
arcs of the work fe'r which this permit is beard(Sec.3097,Civ.C.)
V O Londere No. PLUMBING FE 004
LL H I<ndera Addeves QTY. 'MECHANICAL PERMIT FEE MECHANICAL
OW I cerHtythat l have read thbappliationand state thattheabovelnformatlon aaC
1 Iscore
rct.Iugreeto comply with all tlu tyand countyordinancand state laws PERMIT ISSUANCE FEES PAID,.
>. N relating to building corutmctlon,and hereby authorize repreaentatives ofthas
H z city to enter he above-mentioned property for inspection purposes. ALTERORADDTOMECH. - Date RCC t#
— (We)soles to mi
e,indemnify and keep haress the City of Cupertino P
agamulla illties,' gmenb,costsand expenses whlchmaylnanywayacerue AIR HANDLING UNIT(TO 10,000 GEM) SUBTO AL:
ago' t o d C n race f the gr Ngpf this permit
9 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Ril
'Igv fAppBant -atmo ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TA PAID:
NAZ/Co 1ATERIM S DISCLOS RE
Willthe applicant or future building ompantatore or handle hazardous HEATING UNIT CFO 100,000 BT ) pate RCCC Hill
as defined by the Cupertino Municipal Code,Chapter 9.12•and the —
Ilealthand Saf&y Code Section25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT Li
❑Yes No
Will the applicant or ture building occupant use equipnem or devices VENTILATION FAN(SINGLE RESID) I DATE
which emit hazardous air contaminants as defined by the BerAma Air
Quality Management District? BOILER-COMP O}N OR 100,000 BTlp Aug 6
T Yes nNo
have m.dthehaza ow.terialsrequimm nbunder Chapte'r6.95of BOMER.COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,2M3 and 25534. I
understand that lfthe building does not comently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. rllu aa{/a,___ ,-
responsibility to notify the occupant of the requirements which must he met >tri�a4 L_I_I�llR'R�f11teM!
prior to Issuance of a Certificate of Ooupancy.
—�
Owner or authorized agent pate
TOTAISSUEIJ
L �,[
OFFICE COPY