22772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY Building Project Ede ifftest on - - PERMIT NO.
Building Addrcsa: 22772 7f")
one:
4G ITY OP CUPERTINO-BUILDING DIVISION
Contractor's Name; Lie.Ne: APPLICATION /PERMIT'
BUILDING-E.ECTRICAL-PLIIMBING-MECI IANICAL CATEGORY CONTROL N
.� Architect/Engineer:. L1c. o -
_
QTY , x ELECTRIC'PERMIT t : ,I FEEU,,
T}• BUILDINC'PERMIT-,INFO
Address PERMITISSUANCEi
LICE..NSED CONTRACTORS DECLARATION . .
lh mbyaftlrmthatlamlkeneedunderprwbionaof Chapter9(mmmmc APPLIANCES-RESIDENTIAL 109 DESCRIPTION
ing wdhSvcion7lID0)of Dlvbion3 oflhenusinessand Professions Cede,and my
license Is In toll f��or55�F aai�d effect. PANELS -
DtenxGlams••/(LLic.N_�O Toy KC-�LI
Date�_�N/ Contrador IM IQ 200 AMPS .
/ ARCHITECTS DECLARATION 201-1000 AM[5
OX0 I understandmy plans shall neused as public records OVER 1(X10 AMia5 SQ.FC.FLOOR AREA S/SQ.FT.
Fi z�j Licensed Professional - - SIGNSELECTRICAL E D '
6 .OWMiR-BUILDER DECLARATION - SPECIALCIRC(RT/MLSC. '
09, : owingrason.(hatlam 7031.5xempt,Business
and Contra
ode:Aerse wycfithr �iwAPU T E,R
oo following reason.(Semon 7¢i1.5,Business and Professbne Code:Any city or
O 2" TPMP.METEROR POLE INST.
countywhich
prierrequteaapermitto comuquires theapmvntfee such;or repair
any atrucWrctatemeits that
Is licensed
pursuant to the formihoftte POWER DEVICFS /jn/
�i Roe a signed statement that he b Ilmosm pursuant it the provisions700) of the - - I O//Q/ Z
E5 Con3ofthe License Law(Chapter
ssionsmm)encingorthat he is
xection mptthe00)emn.rof - VALUATION
SOS slon3eflhe Business and Profenlom Code)orthat hebexempttherr(romand SWPIMING IA"70L ELECTRIC '
Yd the basis for the alleged exemption. Any violation of Section 7031.5 by any
<�
p
OITLETSSWI7CFE5-FlXTURF5':a Scant fora Permit sub'FdatheaPPllcant oe civil penalty tyofnot morethan
five
hundredsowner of the 00). NEW RESIDENTIAL ELFGTR SQ.FT, SI'ORIFS TYPE CONSTRUCTION ,
{m . I,cue owner It o property,or he employee with wages r their sole
C or
a c m(Sac.7 K Btaintthewerk.andthes Cde:TheC intended oroffered
w
a�0 dile(Sec.apply
to ahem andf property Code:The or impoves thereon law
bl does not apply to an owner of throng hiswho builds
employees,
p improves thereon,that and
P.'� who does such workhimself orthroagh hieown employees,provided that such OCC.GROUP RFS.UNITS
improvements arc not Intended oroffered forsals.If,however,thebuilding or TOTAL:
Improvement baold within oneyearcfcompletlon,the owner-buflderwlll have . . 1 t,r, -,,1,
tnrMnof proving that he did nor bund or Improve for purpose of sale.). Q'TY. t,'„')' 'PLUMBINGPERMIT FEEr�'� FLOODZONE APN
u I,cue owner of the property,am exclusively mntrading with Ilmmed pFRMCf ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: . ...
i .
The Contractor's License law does not apply to an owner of property who ALTERDRAIN&VENT-.WATER(EA)
bu0da or improve thereon, and who contracts for such p(ojeM -
with a .r•„ .. ,I ,(
cgy(pactor(s)licensed pursuant to the Contradoe.License Law.. , �,.x ' _ ._
LJ t. FEESUiviMdRY!
I am exempt under Sec. B& P C'for this reason BACK FLOW PROTECT:DEVICE
Owner Date DRAINSFLOORRODp AREA,COND. SANITARY -'Y N_
�I WORIO.IANCOMPENSATIONDECLARATION - RECEIPT N- _
01 hereby affirm that I have a certificate of consent to sell-insure,or aFDCRTRESS PER TRAP SCIiUUL TAX Y N=
c mficus of Workenn
'Comperuation Insurance era dBkd copythereof(Sec. RECEIPT X
380,Lab ' GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
RFCEIPCN
C GAS EA.SYSTEM-OVER BUILDING DIV
ISION FEIiSffCnmed
copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
/�gTJl Certified copy is filed with the city Inspection division.
/ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID '
COMPENSATION INSURANCE SEWER SANTfARYSTORM EA 200FT DatRI t#
(Thi;section need not be completed if the permit b forone hundred dollars - e CLYP
($10U)orlen3 WATER Hr. ENERGY FEE Y '•N
'I llnotify that In the Farman in an tmarrerhe work for to broomh this ertNtla issued, '
I shall not employ any pereon in any manner co cue to become subject to the -
Workers'Compewtion Gwe of GWATER SYSTEM/TREATING lltornla.Date PAID
PF NEW RESIDENTIAL PLMB. SQdrG Date' Recel t#
Z p. NOTICETO APPLICANT:Rafter making this Certificate of Exemption,you
should become subpet to the Workers''Comperuation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthis permit shell be
LM j deemed revoked. .. BU - ING FEE
I,
LI CONSTRUCTION LENDING AGENCY _ SEISMIC I
Thereby affirm that there is a construction lending agency for the perform- EL ECTRIC FEE
Z ante ofthe work for which this permit b Issued(Sec.3097,Cie.Q TOTAL:
L) I-nder'.N.me - - PLUMBING FEE -
I— I-.den's Addre.. QTY. .MECHANICALE PERMIT FEE t
O WImnRythat i have read this application—an—d ad
MECHANICAL FEE
I ageeeto comply with all city and county ordinances and Rate laws PERMIT ISSUANCE / ly IrAID:_'
>. y relatingtobuhldingmmsvudion,andherebyauthorlurepresentativesefthis _+/_,y
Z
city to enter upon the above-mentioned property for Inspection purposes. ALTLRORADDTOMECH. —
_ (We)agree to save,Indemnify and keep harmlen the City mf Cupertino Date Rkejptp
against liabilities,pdgmenb,mebanae xi which may In any wayacdue AIR HANDLING UNIT(TO ID,000 ChM) SUBTOTAL:
against said�y conaequenm ofp gran ng of hie permit. AIR HANDLING UNIT(OVER i,oOocm) CONSTRUCTION TAX
/_Iter•- �-1 Da�p.9/
Tnatvre el Applimnt/ tea a Dale EXFIAUS'f}1000(00/DIK'ONS RUCoN.TAX PAID:
HAZA RDOUS MATERIALS DISCLOSURE �� -•
Will the applicant b the future Cupertino
ngocmpantode,store Chapter
fe 9.1Za rdoua HEATING UNIT(TO 100,000 BTU) r' Date Recei tq
material as defined by the Cupertino Munkipal Code Chapter 9.12,and the
- Pkalih and Safety Cody Section 2S532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:- 17
�
❑Yn . rps�No
Will the applleanl oAlAturc build Ing om pant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSU �TE .,
which emit has rdous air cenu mina rota as defined by the Bay Arca Air
Qu lily Management D11111 BORER-COMiDIEP OR 100,000 BTU)
l 4 Yes �Nd 5EP I s 1991
- l have read the haza ouamateriai.requirements under Cha peer 6.95 of BOILER.COMP(OVER 100,000 BTU) _ '
d the California Health&Safety Code,Sections 25505,25533 and 25534. I.
u ndersta rod that It the bu llding don not currently have a tenant,that itis my, - NEWRINDENTIALMECH. - SQ.FF. aa
resporodolity/o notify theoccvpant oft qulrements which most be met fata/l oft//QPI'�IR�
prior to insuancejolp CertlEeatc of Oc pa ry. e -
th�r-d agent � '` - r� f
TOTALISSUED BY:
OFFICE COPY ,