22942 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.,
Building Project Identification PLRM1T NO.
Building Address: 22942
1/'1/1 2
e e ante: tN6 4%67
CITY OP CUPERTINO-BUILDING DIVISION
AlkC tracon' Name: �� it. APPLICATION I PERMIT
k aV BUILDING-ELECTRICALPLUMBING.MFCHAMCAL CATEGORY CONTROL#
ArchltM/Engineer. Llc No:
QTY ELECTRICPERMFF FEEBUILDING PPERMIT INFO
Address:
LICENSED CONTRAROR'S DECLARATION PERMTISSUANCE 15.00 R5
1Q'19 1:1 [1
hereby
licensed under provisions
ofChapter9(rommenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing hSecti.n 7Don3oftheB.dnesdProfedonsCode,andmy
lceseIs In Begateandaffect PANE[S
ULe �
5
LIc.#
Date Contractor —UP TO 200AMM
ARCHITECT DECLARATI 201-1000 AMPS
q�va2 Iundentand myplawal Ubeusdapubllcre�rda OVER IOOO AMPS /`�� FL RAREA $/SQ.FT.
F o(� Licensed Professional - SIGNSELECTRICAL AU t D '
7�«< 4 y OWNER-BUILDERDECLARATION SPGCIALCIRC(RT/M6C M P U T E
wall 7a Ihercb a(firmthallam exempt(romthe Contractor's Llrenee Law for the
following reason.(Section 70315,Business and Professions Code:Any city or
Ff'u� countywhichmquacsapem ttommtmd,alter,impmve,de=l] h,orrepair TGMP.MEfCRORI'OLE INSi',
q� a anystmdurepdortolts Lsaance,aW requlratheappli�antlarsuch permitto E
S file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Q6 3 u, Cootradore License Law(Chapted
er 9(commencing with Section 7000)of Dlvl-
O�+ SWIMMING 700E ELECTRIC
H.W S the basis for teallegnd exemptions Any)violation fSecti pt therefrom and y VALUATION
the Mans for the alleged exemption. Any t tolacivi o!Section se m by any a-10
>a I O ]p/>^ /
<
applicantturnpermitsubjedathe applicant toacivll pealtyana nnre than OUTLETSSWITCHESHJs7URES L. 'el /�( L✓–.
ofivehundreddollarshepro
�I,as owner oft#property,or my employee with wageatMlr sale NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
ZQ compensation,will do the work,and the structure is not intended or offered for
0 Is(Sec.7054,Business and Professions Code:The Contractors License Law
$� does not apply to an owner of property who Wilds or Improves thereon,andOCC.GROUP RIS UNI IS
who doessuch work hnmselforthrough Ms own emplayee,provided that such
ImpowercenHararmintended oroffereciforslt.ff,however,thebuildingor TOTA I0
ImproverrcnHssold withinomyearofcompletiogthe caner-bullderwiil have
tlW.�utden of provingthM he did not build or Improve forpurpose ofsale.). QTY, PLUMBING PERMIT FEE FIADD TONE APN
u S as owner of the property,am exclusively contracting with licensed
cormuch t to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTQt-DRAIN&VENT-WATER(EA)
Wilds or Improve thereon,and who contracts for such p(o)ecta with a
c'ga4adogs)ficensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for thin reason
'
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECFR'I'#
WOR10.5AN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o rola ate of consent to copy
ora RECEIPT#
certificate of Worken'Compenatlon insurance ojac Ifbd copy thereof(Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
valley
W– a�I
Pollryo Y Y !fl � RECEIGAS EA.SYSCEM.OVER 4(EA) DING TM
Co�mpa ray BUILDING DIVISION FEES
I ICen1(Ied copy is hemby famished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rti0ed copy Is filed with len city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP, PAID
COMPENSATION INSURANCE
(Thissrdionneed sabecompleted lftM permit bforom hundred dollars SEWFR-SANITARY-STORM EA.2DOFT. Date Reccei t#
WIW)oifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Irertlfy that In the performance of the work for which thin permit Is Issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING 116 41 So g g
Worken'Compcnsation Laws of California.Date PAID I 1
0 Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEWRESIDENTIALPLMB. SQ,FT. Date Recei tic Qz�O
Fshould become subject to the Workers'Compereatlon provisions ofthe Labor TOTAL:
CC N Code you=at forthwith comply with such provisions orthb permit shall be
> deemed revoked. BU IME BUILDING E ,00
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyaf0rmlhattherelsa construction lending agency for the perform. ELECTRIC FEE I rl
Z ...of the workfor which thin pemdtb Wued(See 3097,Civ.CJ TOTAL:
V Q Lueder'a Name PLUMBING FEE
LL t- Lender's Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W I cerdfythat l Mveread thbapplicatlonend statethatthe above Information
bmrred.Iagree to comply with all city and muntyordlnances and date laws PERMIT ISSUANCE FEES PAID:
} 9L relating to Wilding construction,and herebyauthorizempressetaliveafthls
F N city to enter upon the abovo-meetloned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemedtyan d keep harmless the City of Cupertino Date Receipt#
V against) Wks,jedgmenb,codsand expenses which may In any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agxi CI I.... enceof granting thispemdt.
AIR HANDLING UNIT(OVER 10,000CrM) CONSTRUCTION TAX
Ignatureof Applica t/C odor O to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA )O UR MATERIALS DISCLOSURE _
Will t(te applicant future building occupant store or handle hazardous HEATING UNIT(TO 100,ODD BTU) Date Recei t#
material as defined the Cupertino Municipal Code,Chapter 9.IZ and the T T �Sz(p
Health and Safety ode,Scodh 75532(.)7 HEATING UNIT(OVER 10,000 BTU)
❑Yes �1�'lis'N
Will the applicant or tum building occupant useequlpmea or devices VENTILATION FAN(SINGLE RESID) ISSUA ,DA
which sent hamrdous air contaminants as defined by the Bay Area Air
' QualityManagementBOILER-COMPpIIPOR100,IXpBTU) NOV 61991,
have read the bozo ousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Cods,Sodloa 25505,25533 and 25534. I CITY OF CUPERTINO
understand that if the building does not currently have o tenant,that It is my NEWRESIDENTTAL MECH. SQ.FT.
reporsiblli to notify the ompantofth quirements which most be met
prior to cc aCertifl airy. -
Owner or authorized agent jkta ISSUED BY:
TOTAL: —
OFFICE COPY