22217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
�Huildln Project Identification PERMIT NO.
Buil ding Add iea,: 11 n/7
I C�3I -TCS luGi G G G
w I G�Y�s Fiore: CITY OF CUPERTINO-BUILDING DIVISION
Con nraNa CLie APPLICATION / PERMIT
Arc Ilett Fs m �'re� _ L BUILDIN6ELECTRICA[,PLUMBING-MECHAMCAL CATEGORY CONTQOIIII� '7/
gl en Lic.No: CI 7 L-b
QTY ELECTRIC PERMIT ' FEE BUILDING PERMIT INFO
Address
I'ERhfITISSUANCE x
LICENSED CONTRACTOR'S DECLARATION ISL]'
IMrebyafllrmthatlam Ccemcdunder prwbiamofChapter9(e,and APPEANCESRESIDENTIAL JOB DESCRIPTION
ingwehSection force aid affect.
n3o(nhe BuelnemandlamtemlonsCode,and my
Lica se bin full farce end effect PANELS [�,a••�a-�Ir� a,`, 1
License Clam Lic.p V�CJ
Data Connector —UP TO IN AMI5
ARCHITECTS DECLARATION 2014000 AMPS
pQ+0 7undenbnd my Elam ehalbe used upublic records. OVER]000 AMT'S SQ.FT.FLOOR AREA �$ FC.
E Licensed Professional SICNSELECTRICAL `La••(��-
�GGGG'1� OWNER-BUILDER DECLARATION SPECIALCIRCIAT/MISC
I- ,7s Ihereby affirm that exempt from the Contractor'.License law for the
following mace.(Section 70HS,Business and PmfemWns Code:Anyelty,or TEMP.METEROR POLE INST.
county which requires a permittetconstmat,alter,improve,demolish,orrepair
q anystmc mprlortoilslsatancgals mquimtheappliantformchNrmitto ppwEg DEVICES
PJ file a signed statement that he is licensed pursuant to the provbiom of the
3wF. Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O"J e1an3ofthe Buslnemand PmfmemloCode)orthat he Is eeempttherefromand VALUATION
•77 the basis for the alghe exemption. OUTLETSSWITCI IS-FIXTURES r rn Any violation of Section 70315 by any 'LA
re
app0antfora permit subjecbthe applicant to a civil penalty of not mothan S 1�6 -+� t w
f��undrcd dollars pro NEW RESIDENTIAL ELECTR SQPT. STORIES TYPECONSTRUCTION
I,as owner of the property,or my employees with wages as their sale
peneaHon,wllldotM work and thestructure b not Intended or offered for II �/�y ' '
ale(Sec.7064,BuaInem and Profemiom Cade:The Contractors License Law I A L E D V
. r$ whodoessuch loan meartofprough his
wn employees,
po thereon,and s
does of apply t oan owner orlhaough who b ilds or imp oves the that such
improvements are nM Inlended oroffer d foreale.IQ hawever,/he bulldingor TOTAL:
improvement lssold withinoneyearofcompletion,theowner-bullderwill have
t rden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT ' FE D 2ELI'
L_j L as owner of the Property,em exclusively contracting with licensed PERMIT ISSUANCE m
contractors to construct the project(Sec.7044,Business and Professions Code:
The Commences License Law does not apply to an..at of property who (
Wilds or irepravn thereon, and who contracts fee &VENT-WATER for such pcajects with e EA) % Ql FEE SUMMARY
t licensed pursuant to the Connector's Limn Law. BACK FLAW PROTECT.DEVICE
co
exempt under Sec. B k P C for this..on
OUTSI UP,FI:
DRAINS FLOOIR ROOF,AREA.COND. SANITARY Y_ N_-
Owner Date ns�r�, RECEITX
WORKMAN COMPENSATION DECLARATION p0(TU(Eg.PER TRAP xV/ SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-imure or a RECEIPT X
mrtillateofWorkers'Comper Honlmunnamamdifledmpythereof(Sec.
3800,Lab
lorais CJX
GAS F.A.SYSTEM-1 INCA OUTLETS PARK FFR Y Na0sq I� GAS EA.SYSTRM.OVER4(EA) RECEIPT
N
y BUILDING DIV
ISIONIT[S
Certified ropy is hereby furnished.
❑Certified copy b filed withh the tM city Wpettlon division. CRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID("71' % "7f-9 ,1v7
COMPENSATION INSURANCE $EWER-y1MTARY-giORM EA 2(IOFI. Date Recei t#
(Thlsseetion need not be completed If the permit b for one hundred dollars P
(.$]00)orlemJ WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
Illnot thatIn othe person Inaofthework sorwMobthispermitisblued,
I shall not employ any Laws in any manner so u to become subject to the WATER SYSTEM/TREATING —
WorMmn'Compensation laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.ET. Date Rece1 t#
O NOlicant APPLICANT.It,ager making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
~ N Code,you most forthwith comply with such provisions or this permlbhAl be '
Wj deemed revoked. UI �
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE 1
M Z once of the work for which this permit is issurd(Sec.3097,C1v.C.) TOTAL: xW Ds
02 Lenders Name PLUMBING FEE Cwp�
LL F Lender's Address QTY. MECHANICAL PERMIT , FEE
O mMECHANICALFEF
OIni/ythat l haveread this application and statethattheabove Information ^
Sbcorrect.l agree to comply with all city and mumyordinances and nate laws PERMIT ISSUANCE 4� FEES PAID:
} relating tobulldingeonstruction,and herebyawharberepruentativea ofthls ys
2 city to enter upon the above,mentioned property for inspectlonpurve.. ALTER OR ADD TO MECIL ♦C.V Date ReCei t#
Z (We)agree to save,indemni an d keep karmic a the Clty m Cupnrto. P
against 11 bllid pdg nta,r, a expenses whlcherayleany way... AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
a al ea Y n ue eo the orating of this permit AIR HANDLING UNIT(OVER 10,000 CTM) CONSTRUCTION TAX
Sig. m (Applicant/Con Date EXHAUST HOOD(W/D(XT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS IN SCLOSU RE
P Will the applicant or career building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hoa lth and Safety Cady Section M2(a)7 HEATING UNIT 100,W0 BTU) 6(xj TOTAL
�`
Will the applicant or future building occupant use equipment ordevias VENTILATION PAN(SINGLE RESID) �LY ISSUANCE DATE
which emit hantelous air contaminants as defined by the Bay Area Air
Quality Management D❑istrict? BOILER-COMP OEIP OR 100,000 BT
No
4
Yen d as
Fave read lealth ar sus Code,Se mons 25505,25533
55 ntsunder and 2S534.
I of BOILER-COMP(OVER 100,000 BTU) P O
the erst erniaat If the
4e Safety Code, otcurrntlyh vett and,that It
utporeandytonohfy the occupant
of to currently tenantthat brmant NEW RESIDENTIAL MECH. SQ.R. AUC
rapansibility to notify the ocapant of the rem{uirerrenb which most Mmet
prior to Issuance o(a Certificate of Ompanry. {a f
Owner or authorized agent DataISSUEDBY'�_ ,y7—
TOTAL: I
OFFICE COPY