22874 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
• ISIoe n Project IdendflOtlPEAhBTN
Building Addrm922874
.
caner ams: one: ^ A
F✓fG �Tup1.Ah , ''- �—°/ — DC CITY OF CUPERTINO-BUILDING DIVISION
Con r'a Name: Lic.No: /
/I'- APPLICATION / PERMIT C
Ty-e e fC f Fa�C BUILDING-ELECTMCALPLUMBINGMECFIANICAL CATEGORY CoRiiux X
• ArehorettEngineer. Lie.Nm ._ . . _
t ' '{I 't'!' V" u."uP „BUfLD[NG,PERMITiNFO ` it
- - QIi'iJ L', ELECTRIC PERMIT )r, ( FEEr
AddPLUMS 141�11
e s
- ❑ ❑
` • LICENSBD CONTRACTOR'S DECLARATION-
F4MTISSUANCE
- Ihereby affirm that I am licensed under provisions of Chapter9(commenc. APPLIANCFSRESIDENIAL JOB DESCRIM ION .
ingwith Sedlon7(IDO)of g s�"3olthe BusinessanciProfrsslonsCede,and my . .
' - license is In {d.'. ��bp PANEIS - `
LlcenscCU �N 1 1 r s`t,%'(tsw_ 1 , -
E tractor ad —UPTO DAMPS
A HITEcP E TI N 201-IODO AMPS
0 0 I understated rtry plane ehaB be used v public records OVER IMO AMPg SQ,IT.H.00R AREA 5/SQ.FT.'
-E� Licensed Pro(essloal SIGNSELECTRIC Pas
_ <
6 OWNER-BUILDER DECLARATION.
I UI -'
�' G+ SPECIA,C T/MISC .
.'Iherebyaflmillol]amexemptfrom the Contractor's License Lawforthe
pp
O following reason.(Section 7871.5,Bualnes and Prefessbns Code:Any city or
Z t.®,
K ..i countywhkh requlrtsapermlttocoretru8,altep lmpmve,dennWh,or repair TIM OR POLE INST. -
� any Structure prior to its lenuanen,also requires the applicant for such permit to RDEVICES • '
c.U file a signed Statement that he in licensed pursuant to the provisions of the
0 w Contractor's License Law(Chapter 9(commencing with Semon 7000)of Divl-I - - '
F30 sI.n3.fthA Beeinss.and Prefeaskma Codheinerempt e)orlhat thcrefromand MING POOL ELECTRIC VALUATIOy, _
�'^I the basin for the alleged exemption. Any violation of Section 703L5 by
applicant fora rmitsbb' .thea Meant too civil 1 dnd rtnrethan OUTLETS SWITCHPSFIXCURFS
p$ fine id 1). PP Pero ty W V
W fiv 1,as o d r ofthe500). NEW RESIDENTIAL ELECIR SQ.FI'. ,
�n ❑Las owner of the Property,or my employees with wages r their sok �'1'PE JIy,S77{UCl'ION
C
compensation.wRldothe work and thnstrudureinnot Wended or offered for L N
'$ O sale(See.7044,Business and Professiav Code:The Contractors Llcerue Law
$ does not apply to an owner of property who builds or improves thereon,and
who doessuch work himseR or through his own employees,provided that such
Improvements are not intended or offered for sale.If,hoevep the building or TOTAL. I
w
Improvement is sold within one yearofcompldlon,the ownenboadderwlli have ^f�
e)e rden of proving that he did not build or Improve for purpose of sale.). Q7yii:, r�_.,;pLUMBING;PERINIT,.� , ", '•E':��p�
j_J L as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec:7044,Business and Professions Code:
The Contndors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptokcta with a
cg1_JB[ador(.)IicenxM punuanttolhe Contrador'e License Gw: ]LACK Fl.OW PROTECT.DEVICE - �r j''Il FEE OUT,SUMMARY*''1 • ',,,7
II am exempt under Sec. B k P C for thin reason
ES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N— ,
Date - RECEIPT
WORKMAN COMPENSATION DECLARATION pg PER TRAP SCHOOL FAX Y— N_
C31 hereby affirm m
that I have a rtiRapp(�(
te of consent to self-Insure,or RECEIPT M
certifiate of Worken'Comperuatlonlwurance ora certified copy thereof(Sec. GAS EA.BYSI'FM-1 INCA 3a00,I#DC.) L✓� 2Z..3 S_9 / ", PARK rEe Y N
PoliryN J - n GAS EA.SYSTEM-OVER4(EA) - DING DI'M
; Com an / Qom' /.J '� '. BUILDING DIVISION FIiES
Certified copy b
Certified ropyin(IMd with
the chercbythe city inspection divlaon.d. '. CREASE/IND USIRLWASIEINTERCEPTOR PLANCFIECKFEE
^ ❑
CERTIFICATE OF EXEMPTION FROM WORK EBS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FE. Date R2CC1 (N
(Thlasoctian need nd be complded lithe permit inforonc hundred dollen
($100)or.IcesJ WATERHEATERW/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for vvMch this permit is Issued, —
I shall not employ any person In any manner So u to become subject to the WATER SYSTGI/TREATING
Worker.'Compensation Laws of California. Date _ PAID
O Z Applicant
. Z O NOTICE TO MPLICANT:If,ofter makingthin Certlfleate of Excm)rtion,you NEW RESIDENTIAL PLMB. SQ.FT. Date Rece1 t#! ,
Fshould became subject to the Workeri Compensation piovbios ofthe Labor TOTAL:
M
Code,you=at forthwith comply with such provisions orthls permit shall be
> deemed revoked. - BUILDING FE•
dp " CONSTRUCTION LENpINc ncwcY - SEISMIC FE•E -
Z Thereby aflmothat there be construction lending agency far the perform ELECTRIC FEE
-� an oflhe work forwhTOTAL:
ichthis permit B Issued(Sec.3097,Civ.C.) - -
V O . I.endara None - - l PLUMBING FEE
IL F Ienaae.Addmss QTY."tj;��-MECHANICAL'PBILMIT�:J.',•li;=FEE'li MECHANICAL
O O I certifythat l have read thisappliationand State thatthe above information
0rorrect.I agree to comply with all city and county ordinances and State laws PERMIT ISSUANCE FEES PAID:
Y'N relating to building construction;and hereby authorize representatives of thin -
HZ city to enter upon the abovcmentioned property for inspection purposes. ALM OR ADD TO MECH. Date Reeei IM
V - (We)agree to save,indemnify n d kee harml the City of Cupertino P
against liabilitfe,' dgment n x e Ichnayleanywayamme AIR HANDLING UNIT(170 10,000 CFM) $LIBTOTAL:
airs dC enc t e ng tMa permit _
G6_�SMR HANDLING NIT(OVERIO,WOCM) COIV$TRUGTIONBT
SI v o ppl nt/Co trac r Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
WBl the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 105,000 RTU) Date ReceI tN
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the -
I lealtle and Safety Code Section 75537(.)7 HEATING UNIT(OVER IDQ000 BTU) TOTAL
❑Yea No
Will the applicant or future building occupant use equipment ordevices VENTILATIONFAN(SINGLE RESID) NCE DATE
which emit hazard....ir contemioams as defined by the Bay Area At,
Quality Management District? , BOILER-COMP(3HPOR 100,01M BTU) ;•�� .
�I yea ("1 No
have read the hazer u.materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the Celifemat I lealth A Safety Code,Sections 25505,25533 and 25S3d. I
.understand that lithe building does not currently have a tenant,that it in my NEW RESIDENTIAL MECH. SQ.Fr
responsibility,to notify the oc ant the igq�eAt. hi It on the can
prior to taxn d Ace to o Pa ry/e—"
Owner or a7lhmlQd agent Date
TOTAL: ISSUED BY:
OFFICE COPY