22788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
.Building Project Identification - PERMITNO.
BuildingAddress: urn cs a 2
7 8 8
2
wnere one: G G lT JS TVS
Tff-
_Raa�;v.�S 1•�f�i UL► CITY OF CUPERTINO-BUILDING DIVISION d
Contraters Name: LIc.No: APPLICATION / PERMIT `2-�—`1
BIJILDINGdEC11iICAU7'LIIMBINGMFCHAMCAL CATEGORY CONTROL#
Arch t< F-r Lie.No:
t! E•LfiCTRIC PERMITI I1�1'�•tL.' ' BUILDING PERMIT INFO,
,,FEE' '
Addrcae: ��l PLUMB
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION 11•
Ihemby affirm that l am licensed under provisions of Chapterg(commeric, APPLIANCMRESIDENTIAL JOB DFSCRB'IION
Ingwlth Sccd a7000)ofChvi.on3ofthe Buslnessand PrefemionsCode,and my
license la in full n fact. / d PANELS
Llmnec C1. Llr � av1
Date /a4 ontrador GAJ —UP TO 2DOAMI!5
GHITECPS D CLARATION 2014"AMPS
q�q�uu�O Zp I understand my plans shall be used as public recorda. OVERIOOOAMPS SQ.FTJLOORARFA $/SQ.FE
Fi Z Licensed Professional SIGNS ELECTRICAL
- GGA 6 OWNER-BUILDER DECLARATION SPECIAL C1RCUlT/MISC -
s' I hereby affirm thatI am exemptfrom the Contractors License Law for the
OpZ1 t-
TEMP.MIIPR Oft POLE INST.P � en tywhchrcqu1 sapemitt..wtuct,alteplmproedemlsh,ore it
anystmettue priorwits issuance,lao requlreatheapplicant for uch permitto POWER DEVICES '
K file a signed statement that he is hounsed pursuant to the provisions of the "
3 w Contractor's License law(Chapter 9(mmmencing with Section 7000)of Owl-
O�'+ SWIMMING POOL ELECTRIC
the
thealle alleged exemption.
Any violatorthaion
he la exempt there(romand VALUATION -
Sn'g the bash for the alleged evemptlrn. Any vlolatlon of Section 7031.5 by any
< applicant fora permit subjects
theipplicant toe civil pawky f.ot more than OUTLETS-SWITCHES-FIXTURES
five hundred dollars(5500). NEW RESIDENTIAL ELECTR
L as owner of the property,or my employees with wages as their sole c"Q,FT' STORIES TYPE CONSTRUCTION
t Zz RISIRJTTS
compensation, el
w0ldothe work and the structure Is not Intended or offered for
$a ❑ sale(Sec 7044,Bun..and Prefemre loCode:The Contractors Li...Law '
p3R does not apply to an owner of property who Wilds or improves thereon,and ' .
CIN, whodocssuchworkhErdEforthmagh hisownempleyees,provided thatsuch OCC.CROUIr
_
improvements are not]mended oroffered forsale.If,however,the W ltding or TOTAL
improvement issold withinoneyrarofcomplMlon,the owner-bullderwlll have p
tis +Men of proving that he did not Wild or Improve for purpose of sale.). QTY, �',)•I� 'pI.UM$ING PERMIT a�` •,r,FEE �' 17CODPONE APN
LJ 4 as owner of the property,am exclusively centrating with licensed PEWITISSUANCE
contractors to comtrect the project(See.7M4,Business and Professions Code:
The Contractor's License Law does rat apply to an owner of property who ALTER-DRAIN 4 VENT (FA)
Wroves contrera - -
builds or impthereon,and who
for such p(oje with a „s..
co doKQhoraaed punuant to the Contractor's License Law. BACK FLOW PROTECT DEVICE I EESUMMARY '
Lf I am exempt under Set . B At P C for thie'reason
QIITq[nr r;-ES
Owner Date DRAINS-FLOOR,ROOPAREA,COND. SANITARY Y N—_
IOEC
WORKMAN COMPENSATN DECLARATION REET#
❑I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAP SCHOOLTAX Y N
certificate of Workers Compensation Insurance ore certified copythereef(Sec. RECEIPT#
3500,La), �' a�lj//I'O (J GAS EA.SYSTEM-1 INC4 OUTLETS PARKME Y_ N—
PolicCom ✓ (OT' ( GAS F.A.SYS EM—OVER4(EA) ' RECER'IM
Com any BUILDING DIVISION FEES
ertified copy is filed with the cityinspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PL.ANCI-IECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SLIVERSANTTARYSIORM EA:MFT. Date ReceI t# -
RhisaectionneedratWENSATI NI SURApermib/Drone hundred dollars
($100)or less.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit In Issued, —
I shall not employ any person In any runner so as to become mbje t to the WATER SYSTEM/TREATING
Work<n'Compenaation Gwsof Glifamla.Date PAID
O Z " ;Applicant -
Z 0 NOTICE TO APPLICANT:If,after making this CertRlcate of Exemption,door
NEW RESIDENTIAL PLMR._SQ.FT. 'Date ReceI t#
sh.ld become subject to the Workers'Compensation provisims of the Lor TOTAL:
i N Code,you moat forthwith comply with such provisions or this p<rndl shall be B
7 deemed revoked.
LU
p CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I hereby affirm that them la a mmtrutlon lending agency for the perform ELEC'T'RIC FEE
D Z ance of the work for which this permit is Issued(Sec.3097,Civ,Q TOTAL:
00 Ircnder'e Namei . PLUMBING FEE
LL F Lerdcr.Addmaa QTY. MECHANICAL PERMIT'' FEEL MECHANICALFEE
O W Icedifythatl have read this application and tate thalthe above Information
1
Escorted.I cgereto comply with all city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID:
'} W relating to Wilding comtmtion,and hereby authorize representatives of this -
F Z city to enter upon the above-mentioned property for inspection purposes. ALTQIORADDTOMECH.
(We)agree to save,indemnify an d'keep harmless the City of Cupertino Date ReCCIJ)t#
against liabilities,jud nb,orsLand azpenees whichriayinanywayaccme AIR HANDLING UNIT 10,000 CFM) - SUBTOTAL:
ym nsogq -sw'ng of hls pemsit ALR HANDWNG IJP TT(OVER]O,000CIM) CONSTRUCTION TAX
re Appllcent - or 00IAUST HOOD(W/D(1CT) CONSTRUCTION TAX PA[D:
HAZDO .RIALS DISCLOSUREtheapPllontor re building occupant atom or handle hazardous HEATING UNIT CM 100,000 B1'[J) - Date RCCCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the -
Hesllh.nd Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yesr(��I No
Wllltheappllcant or fu turn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mntaMnants as defined by the Bay Area Air Q. Thy Management Dlslrkt7 BOILER-COMPOHPORICCOMSTU)
r�. 4Y9'I .',OND
haver lit the Faze Safety
Code,
Sections 25505,25S33
Chapter. 1 of ` BOILER-COMP(OVIIIll00,0006TU) RA
the Gltandt Health building
Code,cut
corsntlyh have
ate rad,that i
understand that If the building does not errantly have atenanq that it is my NEIN RESIDENTIAL MECFI. SQ.R.
LM
-understand
to notify the occupant of the requirements which must be met piiortoissuanceofa CcAlfiateofOccupanq. OCTV/ ry�
Owner or authorized agent • Dale �.
TOTAL: - ISSUEDB
OFFICE COPY