22347 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building,Pro'en Identification PERMIT NO.
Building Address: ��O22347
me: one:
Eer. �• CITY OF CUPERTINO-BUILDING DIVISIONAlk p a
^ha °:," : LI /"n' APPLICATION /PERMIT
\f`1 6"O . BMDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTRNL I���j Q
Architect/ groes Lie.N.: GJ
QtY ELECTRTC PERMIT'' SGP. ' BUILDING PERMIT INFO
Address
/ PERMITISSUANCELL'
LICENSED CONTRunder rDECLARATION
Ihereby affirm M)olam licensed oftheBrprovLalomo(Chapler9(rommme- APPLIANCESRESIDENTIAL IOD DFSCRPDON
Ii...I Section 70W)of d effect
Buancaeand Protesalon.Code,and my
licenx la in full de((ect. / �a PANELS
LI=enm r'f1am LI[.N IOLlF7 � r 1
mCHITECr �Ea(f' IK4'LLI,,TO 2DO AbTS
ARCHITECTS DEC
sp RATION 2VER 10AMI'S
�2 ]understand my plain shailWused as public records. OVER]IXO AMI+$ �.S-rQ.aaF��fyHt�sr.��O.O��R AREA SIS/�SQ.Ff.
O SIGNSELECTRICAL / Ije./�I ' CKCo
Licenced Professional L �L�r--NI`'�J
OWNEReBUILDER DECLARATION
fn SPECIAL CIRCUIT/MLSC
zn, .wing monrmthal..7031 ,B frons and or's License
LawAny fort he
oo countingreason.(sectionrmit to onstructand Pimprve, Code:Any cityir
TEMP.METPR OR POLE INS?.
P�
county wMmpch r norms• anct a construct, aplimntf ,such,er ttr
file a sutture tatementa that
he
pursuant
to the(.nuch perfNt a T'OW'ER DEVICES
µ file a signed statement that he h(Chapter 9(coin pursuant it the tion 7000)of
of the
µ� C.m3ofte .sins LawlndProssionsmm)or cingthat with xempttherefom Ivi-
and SWIMMING POOL ELECTRIC
sion3of the Business and Professions Code)orthet Mane exemptthere(romand VALUATION
S° the basis for the alleged exemption, Any violation of Section 70415 by any n^
applicant I..permit subjects the applicant to a civil penalty of act more than OUTLETSSWITCHESFIXTURES /Ot
five hundred dollars($500E.
R Cc ❑I,as owner of the pmperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ,FT. STORIES - TYPE CONSTRUCTION
compensation,will do the work and the structure R not intended or offered for
O sale(see.7044,Business and Profeasons Code:The Contractors License Law
�$ does not apply to an owner of property who Wilds or Improves themes,and OCC.CROUP RFS.UNITS
does such work himself.,through his own employees,provided that such
ImprovemcnUamrw tendedorofferedfmmic.I(however,thebulldlegor TOTAL;22,60
Improvement bsold withinuneyearofcomplelloo,theawnci-buuderwlll have
thgJ;urdeno(proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FIAODZONE APN
L L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the prefect(Sec,7044,Business and Profemloes Code: (�
The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER RIA)
or Improve thereon, and who rontraca for such pM.jem with a
, tt ctor(a)licensed pursuant pursuano the Contractor's License Law. FEE SUMMARY
LJ[amexempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND, Ov' - SANITARY Y N
Owner Date - RECEIVEp
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP �W SCHOOLTAX Y N—
❑I hereby affirm that I have a ce a...o of consent to op self-insure or RECEI TT N
Mal,abC.) rken'Compevatlon Insurance ora certlkd ropy thereof(sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800.Lab CJ
Policy p CAS F.A.SYSTEM-OVER 4(FA) RECEIVE p
Co any BUIL DING DI VI SION IT ES
MCcrtlfied ropy is hereby famished. CREASE/INDU57RL WASTE INTERCEPTOR PLANCHECIC FEE
C.i Certified copy is filed with the city Inspection division.
A' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID (-{) L CJ t�N �•q
COMPENSATION INSURANCE SEWER-SAN T.nitY-STORM F.A. 007r Date Recei !III-� I
(IMlsaectl.n need rat M completed]the permit le(.,caro hundred dollar s
(SI00)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that o the performance.(the work so as to b this permit is Issued, —
I shall not employ any person
ws In any manner n as to become subject to the WATER SYSTEM/TREATING
Worlicrs'Compensation laws of California.Date PAID
O Z NOTICE[ Date Recei tII
Z O NOTICE TO APPLICANT.It,after making this Certificate,of Exemption,you NEW RESIDENTIAL FILMS. SQ.FI.
shauld become subject to thekers'Comperuatlon provisions of the Labor TOTAL:
CC W Code,you=at forthwith comply with such provisions orthls permit shall be
j deemed voked. U •ING • e
al7 reCONSTRUCTION LENDING AGENCY SEISMIC FEE aLT
Z IherebyafO,m Nat there h a construction lending agency for the perform, TOTAL:
U ELECTRIC FEE Z
ance of the work!.r which this permit is issued(Sec.3097,Cle.C.) e
O leader.Name PLUMBING FEB lux
LL Lender.Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL PEE O
O W IcrmIfythatlhavereadthb appliCtW..M tatnthattheabovein!°r=tim ��{
Iscoreact,I agree to comply with all city and county ordlnancesand state lata PERMIT ISSUANCE 2W FEES PAID:
O• relating to building roretroctlon,and hereby authorize rcpresentativesofthb ...a
H fA city to enter upon the above-mentioned property,for Inspection purposes. ALTER OR ADDTOMECH. ', a3
? (We)agree to uva,Ilia emNfy an d keep ha the City Of Cupertino Date ReCeiptp
V agaWtli bNtlea,' ate, .:.Rdexpe^ ch mayleanywayaccrue AIR HANDLING UNIT(TO 10,ODOCFM) SUBTOTAL:
ag.l sa1dC nacquentt the gr (this permit.
n
MR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
St urapfAppilant/Contract arc R EXHAUST I IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture Wildingoccopant store or handle hazardous HEATING UNIT 100,C)DO BTU) Date Recei tit
m5terial as defined by the Cupertino Municipal Code,Chapter SAL and the
Health and Safetycod.Sadmr 25532(.)7 BEATING UNIT(OVER IDQ000 BTU) TOTAL:
❑ Yee M No
Will the•Praia.or.il building fl.a use equipmentor.Air devices VENTILATION FAN(SINGLE REBID) ( DATE
which emit hazardom air rontaminents as dented by the Bay Arca Alr N1�R
Quality Management District? BOILFR-COMP 0HPOR 100,000 OTU)
4 Yea 9 No
Yea
read the baza o.. enals requlrerrrnb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BID) 111
the California Health k SJ! Code,Sect lone 25505,25533 and 25534.] VF
understa rad that if the building does not currently have a tena nt,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupa racy. GN
qAA�[[ jl'IVI!
�6/VYI�
Owner.,authodredagent Data - ISSUEDBY'
TOTAL. 1
OFFICE COPY