22807 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address 22807 2^0 7
nems acre, one: G G jV( I
L �.J F'3�v1-C� CITY OF CUPERTINO-BUILDING DIVISION /���_BM
o N ma: /60
- APPLICATION / PERMIT L `-1
C-0 35 LCC r BUILDING-ELECTRICAL.PLUMBING-MECHAMCAL CAITGORY CONTROL#
Architect/ ne - Lk.No:-
`'- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. SAL6 E&M &p PERMITISSUANCE ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby afftrmthat l am licensed under provisions of Chapter9(commenc APPLIANCESRESIDENIAL JOB DESCRB'7ION
Ing with inh1g7000)of Dl if d. o(thegumnevandpro(vmonsCade,and my
license la In fu re"and if d. PANELS
License Cl Lostr
nate Contrsctor 201-1030 AMPS
UP TO 200AMPS
RCHallbe used
LAA I N SQ.IT.FLOOR AREA s/SQ.FL.
0 2O I understand my plan shall be used v public remmdd. OVER 1000 AMP$
Licensed Professional SIGNS ELECTRICAL E. ® I N
6 q OWNER-BUILLDER DECLARATION \ 'A 1 l ^ ly
In a LicenseSPECIAL CIRCUIT/MISC J 'tll'LLLia...11lhlllTF
C,9eeesa
y owing raffirmSuton 70315, frons a Contractor's Code:Law fart he
Q following reason.(Section 70315,Rumness and Professions Coda:Any city it
� I"Iy a.untruchuh rcqubesapermne,aro requiesthaprovgdemolbh,or repair TEMP METER OR POLE INST.
ra 7 anystructure prior tolb Issuance,also requlreatheappllant for each permit to D TE
ry1 file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
30t�, Contractor's License Low(Chapter9(mmnstnctng with Section 7000).(Divi- SWIMMING POOL ELECTRIC /
man3 of the Businessand Profeealose Code)mthat he b exampttherefromand VALUATION
�ss�kr��
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTIJRES e,y
applicant fora permit subjectstheapplicant to a civil penalty of not orethan 0 00�
R five hundred
mner of the Pr. NEW RESIDENTIAL ELECIR SQFT. STORIES TYPE CONSTRUCTION
..�n ❑I,ea.weer of the property,or my employees with wages r there dole
7< com(Sce,70A BusinesandIkformor Code:
C intended.I,x,.d for
Law
p dile(See apply to an ow and f property Code:The Contractors Greve law
does one apply toan owner of property who norlmproovidedsses rthRand OCGGROUP RES.UNITS
who does ons amrkhimself ed orxugh Moown .If,ho employees,provided that such
Improvement uredo Intended earofc (oleate.thhowever, ilderwdingve TOTAL:
Improvement within.neycaro(completmn,theowner-bullderwillhave
t)grkuMen of proving that he did not build or improve for purpose ofaale.). QTY, PLUMBINGPERMIT FEE pLODp wNE ApN
L j L as owner of the property,am exclusively contracting wfth licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Profevlom Code:
The Contractors License Law dues mi apply to an owner of property who ALTER-DRAIN kVENT-WATER(EAI
Wilds or Improves thereon,and who contracts for such ppojecb with a
cgp(TactoKe)Ecensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LI I am exempt under Sec B Is P C for this reasonOUTSIDE FEES
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIT M
WORKMANCOMPE'NSATIONDECLARATION FIXTl1RF8 PER TRAP SGi00[.TAX Y_ N—
'rcby affirm that I have a certificate of consent to self4exure,ora RECEIPT M
ce Iflate of Workers'Composation Insurance are certRled cvpythereof(SecB�if . GAS EA.SYSTFM-1 INC.40U7LET5 PARK FEE Y N
3801 Lab C��''� (�"
RECE
Cam any GAS EA.SYSTEM-OVRR4(EAJ DING DTN
a herb BUILDING DIVISION FEES
Certified copy 6 hereby with
ithe city
Certified copy mpybfiled with the city Inspection division. GRGSE/INDUBTAL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
Cot beco
COMPENSATION INSURANCE SEWER-SANITARY-STORM E4203FT Date RL i t#
Rhos Ism.) need not be completed if the permit Is(mesa hundred dollars
($100)carilev.) WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
(certify thato the performance I.aof ny
permit booed, —
I shall na employ any person In any manner,so v to become subject to the
O R
WAT SYSTEM/TREATING Workcrs'Compematlon Gwa of Callfornla. PAID "
Date Z Applicant -
Z O NOTICE TO APPLICANT:If, free nukl.g this Certificate of Exemption,you NEW REBID=AL PLMB. SQ,FT, Date Recef t#
Hshould become subject to the Works.'Compensation provlsloes oflhe Labor "TOTAL:
f/2 Code,you must forthwith comply wlihsuch provbionowthm pereetdhall be
> deemed revoked. BUILDING ITE
jLCONSTRUCIONLDVDINGAGENCY SEISMIC FEE
I hereby a(Orm that there b a construction lendlegagenry,for the perform- ELECTRIC FEE
� Z ance of the workfor which thbpereolt b bsind(Sec.3097,Civ.C.) TOTAL:
O O Larder's Name PLUMBING FEE
IL Lander',Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcertifythmlhavtrexdthlsappllati.nandstatethafor
ttheabovefnmatlon
Ismrnect.I agreeto comply with all cttyand county ordinances and mate laws PERMITISSUANCE FEES PAID:
,> a relating to building construction,and herebyauthorize representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALMORADOTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabNties,judgments,miss and expenwswhich mayln anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
'agaI Ed tyln nuquenre.(the granting and this permit.
14
MR HA CONSTRUCTION TAX
O
Sigmtureo(Applicant/Contractor t EXHAUSTIAUST HOOD(W/DIK:T) CONSTRUCTION TAX PAID:
ZARD
HAARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTI)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Recci t#
Health and Safety Cod cdon 25532(a)7 HEATING UNIT(OVER 103,000 BTU) TOTAL: U
R
Yee o
N the appllantfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which tout hazardous air conlammure ad deflnM by the Bay Area Air
iia lity Management l 7 BOILER-COMP OHP OR 100,000 BTU) P�
4 Yes o D
I havernia thehazes fetyCeedab rcons 25505,25533 and
2S54.I of BORER-COMP(OVER 100,(M)D BTU) /D^
the California tHealth the building
have
a tenant,
25534.1 I 1
understand that if the occupant
of
a mquiyments tenant Lust it is NEW RESIDENTIAL MECH. SQ.FT.
responsibility to natty theompant of the requircmente which must be met tea
pr ceofaCertlfk of Occupancy. /
Of
Owner or net o�agent I ate f �
IOTAL-. ISSUED RY:
OFFICE COPY