22734 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
a0Building Project Identification PFRMIT NO.
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A A A GE Q �4 99G-r /D� CITY OF CUPERTINO-BUILDING DIVISION ( ��
Contrarto Mm
ae: Lie.No: APPLICATION / PERMIT
Lk.No: BIALDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL N
Architect/Englnar.
QTY ELECTRICPERMrr FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE t -tea LJbLI
p N N
LICENSED CONTRACTOR'S DECLARATION jC7\
t rJ�
I hereby .i7").lam licensed annaoffe am r9de,and c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ii...i infonforceanDiWslon3-fthegusincasandPro(essionsCode,andmy ��� 2�sa�,,,DTL
Licomi Is Infull force and diad. PANELS �R����V7 DT-L
Llansc Class LIc.N �� QD6L
Date GrUP TO 2DO ANUS
ARCHITECTS DECLARATION 201-1000 AMPB
�qqp++NOL I understand my plans shall W used as public recoNs. OVER1000AMP5 L—S.DR Ifl S/SQ.FT.
Ed t, LlcensedProfesslovl SIGNSELECTRICAL P U T E R
6^(M OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
I hereby of lmothzt Ism exempt formthe Contractor's License law for the /�
following reason.(Section 7071.5,Business and Professions Code:Any city or .T
F f'� countywhichrequireaapen ttoconstruct,alter,tmpmve,de=lbh,ormpalr TEMP. OR POLE INSI. `� y� j
Y�,�,,JJ.: anystmcture prlorto Its lsavarec,also requlrestheappllcant for such permit to
'�V file a signed statement that he 6Ilearsed pursuant to the provision of the POWER DEVICES
bac' Contractor's License Law(Chapter 9(commencingwith Section 7000)ofDivi- SWIMMING FOOL ELECTRIC
�0a son3ofthe Businemand ProfealovCode)orthat he6exampttherefromandVALUATION
t
yd•�] he bv+b for the alleged exemption. Any violation of Section 7MIS by any C MM /a,.
�Qa ppbeart fora permitsubjects the applicant to a civil pevltyofnot morethan OUTLETSSW[TCHESITXITJRFS 1 2J,OVC QD
qqq ndred dollars(85011). NEWRESIDFNTIALELECTR SQ,FT, STOW Eq 'M'E CONSTRUCTION
owner of the property,or my employees with wages as their sok
1 XX 'mpevatlon,wBldothework,andthestructurebnot Ntended or offered for
5 O le(Sec 7614,Business ami Pref nedov Code:The Contradors License law
�, �$ don not apply to an owner of property who Wilda or improves therron,and . R
who does such work himselforthrough his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuilding or TOTAL: OCCCROUP is.UNITS
Improvementbsoid wilhinaneyearofcompietlon,the owner-buileferwlll have
t"relan of proving the he dm not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE ---T l 000zONE APN
Ll 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEG'�
contractors to construct the project(Sec 7004,Business and Professlov Code: �.�
The Contractor's License raw don not apply to an owner of property who ALTER-DRAIN 9a VENT-WATER(FA)
cz
Wilda or Improves thence, d
eon, and who centras for such pWjem with a
�gRl�a0.Rs)Iloerucd Pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this re
• Owner Date awn DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a certlfivte of consent to sell-Insure,or a FORURF_S PER TRAP aJ SCHOOL TAX Y N
certificate o(Workera'Compematlon Insurance ora cenifkd copythereof(Sec, RECEET N
3800,Lab C.) GAS EA.SYSTEM-11NC.4 OUTLETS PARK FEE Y N
Policy N — RF-CEQ'T N
Com any GASEA.SYSIEM-OVER4(EM
ffCenifled copy is hereby furnished. BUILDING DIVISION FEES
❑Certmed copy filed with the city Inspection divisirn. CREASE/INOUSTRL WASTE INTERCEPTOR PLANCHECICFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA-SETRAP PAID
COMPENSATION INSURANCE
(rhlssadlon need not becompleted lithe permit 6forone hundreddollars SEWER-SANITARY-STORM FA.200]7. Date Rem! t#
(El I ot"il thi WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
thato the person
so as to beorpematcito ti; —
I shall not employ any person In any manner so as ro become subject m the
WorCompensation laws of California.Date WATSYST /TRFAnNC
Z PAID
O Z I ApplicantiCalifo . IX UI
O NOTICETture...ICt to
orkers'Comarution p ova Exemption,you NEW RESIDENTIAL PLMB. �,F7. Date Recti t#
fshould became aubFct to the Workers'Compeva0on proWiov of the Labor TOTAL:
N
Code,You=at forthwith comply with such Provision orthb permit shall be
W > deemed revoked. BUILDING FEE
IL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there 6 a contme ien)ending agency for the perform ELECTRIC FEE
7 Z .runt the work for which this permit 6 issued(Sac.3097,CIv.C.) TOTAL: a
LL O Lende�.Adde PLUMBING FEE L
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceni(ythaH have read thio applivtbnand etatethatthe above information t,
is corned.l agrato complywith all cilyand count ordinances and state laws PERMIT ISSUANCE aaqv� �1
} N relating to building controctlomand hereby authomm reprnentauvn ofthb LIN t'5e`-+a FEES PAID:
city to enter upon the above-metloned property for bopeckn purposes. ALTER ORADDTO MECH.
— (We)agree o save,Indemnify an d keep harmless the City of C-panto Date Receipt#
.g. 11 e,judgments,cortsand expenses which maylnanywayaccrue AIR HANDLING UNIT(TO 10,"CFM)
agar aid icyin n molthe gofthlaparm¢. SUBTOTAL:
AIR HANDLING IlNTf(OVER t0,00pCF:M) CONSTRUCTION TAX
Slgroreof pp ran -tractorDate EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS Di CLOSURE
Will the appllnntor future building occupant store or handle hazardousNt
T(TO100,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCei t#
❑MeaHealth d SafetyCod'lNoSection 75532(ap T(OVER I W,000 BTU) TOTAL-
WllllhezppRtantorfunre buildingoccupant defined
ndby equipment Bay Area
devices VENTILATION PAN SINGLE RFSiD) e� ISSUANCE DATE
which emit hazardous air centamivnls as dented by the Bay Arca Alr `_i OHP OR 100,0(0 BTU) PAID
mOde, etions requ 2rrcnb5533 aChapter. 1 of (OVHi 100,0008'TI))the Califomla Health&Sa(etyCode,Section 75505,5$73 and 25.53d. 1understand that ifthoWilding don not currently have a tenant,thatit6myTIALMECH. SQ.IT st`P 1 ry gAgj
respovibilityto notify the occupant of the requirement:which must be met A /
prior to Issuance of a Certificate of Occupancy. /
Owner or authorized agent Date 04 n 111"D
TOTAL: ISSUED B ._
OFFICE COPY