22092 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BUIIdin Project lderu f radon „i PERMIT NO.
Bulldleg Address: -
Len lie q 640► 220.92
nerBName: Orle: IAIL
c��k.j— I( G�,B• -Y CITY OF CUPERTINO-BUILDING DIVISION►� y , _
Contractor's Name: ( ur.Nn APPLICATION / PERMIT
- BUILDING-LLECTRICALML BING-MEC LAICAL CATEGORY CONTROL#
AKMIttI/Fngioner.- Lk.No:
QrY',=L ',,ELECTRIC PERMIT '4- .zFEE� :=�+" aBU1LDING'PERMIT;INi'O a*I:•
Address PERMITISSUANCE l�D ❑
LICENSED CONTRACTOR'S DECLARATION �YV
[hereby affirm that l amlicemed under provisimsof Chapter9(rommen APPLIANCESRESIDENTIAL 103 DFSCRIPIION .
ingwith Sectlon7OW)of Division3ofthe Businessand ProfessonaCoae,and my s '
license ie in full force and effect. - PANELS
License Class Lie# T
'Date Contractor - UP 1 TO200 �L.'l �.%AAJ 4,e
i(1MP5
ARCHITECTS DECLARATION
06 Iunderetand my plaru shall be used as publlcremrda, OVER IOOO AMPS F[FLa]$A$� .' S/$Q.FT.
I�rG? Licensed Professional SIGNS ELECTRICAL LED ,
OWmNER-BUILDER DECLARATION• C
]f' , IhercbyafOrmthat lamexept(romlhe Crntrador'elicen.e law for the SPECIALCIRCUIT/MISC
SM P Uar
o-. r#$q/
O�Zt qqqfollowing reason,(5MIot7031.5,Business and Professions Code:Any city or TEMP.MEITR OR INST.
'countywhlch requlrcsa permlitocorstmct,alter,Improve,dennlish,orrepalr C
$ nystructure priorto Its issuance,also requlreatheapp3ranl for such permit to POWERDEVICES
file a signed statement that he Is licensed pursuant to the provisions of the r -
O,w Contractor.License Law(Chapter 9(commencing with Section 7000)of 30 DWI- VALUATION n�^ slon3 ofthe Business and ProfesalorniCods)orthat he Li therefromand SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7011.5 by an OUTLE7SSWITCHFSFIXTURES - 3.4 D. �
0 applifora permit subjects the applicant to a civil penalty of not nnrethxn
five 1,as o nerof he pr.` SQ STORIES TYPE CONSTRUCTION
- NEW RESIDENTIAL ELECTR FT.
Q.. Q' I,as owner of the property,or he employees with wages as their dole
a,, ate(Se cation,w..fine he work,and lhasC de:Th Contraet ctor's
or oRered for -
O
ate(Sec.70K to aniowandf property Code:The Contractors Limner law -
3� docs not apply torn owner ofpropertywho
ovoTbuilds orlmproovidedreoryand - OCC.GROUP - RIS.UNITS
who does
mnts amwork himself dedoraughhiaowneor .If,ho thatsuchding,
Improvements sold Intended plaior.the weveg deer illhavr - - TOTAL:
improvement Asold salthlnoneycarofcompidlon;the owner-bullderwili have ,,, �
tIR•eb .ed n of proving that he did me build or Improve for purpose of sale.). 'QTY. 1I."'••»PL LIMBINdPERMIT.' •1",V `.3`.FEE { .
ru I,ae owner
of the property,am exclusively contracting with liormaxi FLOOD ZONE - MIN
c trattom to construct the period(Sec.7044,Business and Professions Code ( PERMIT ISSVANCC I� UD
The Contractors License Law does not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(FA)
Wild. or improves thereon,and who contracts for such plujeds with a - t
rg0.t;actor(d)3cens°dpunoanttothe Cmtmdo sLlcenw Law. - {, i�•�'� {,�'%',FEE SUMMARY,;,.
IJ I e unr�tc. B k P C for th(e reason s BACK FLOW PROTECT.DEVICE - =-
C„V�(y� Date / DRAINS.FLOOR,ROOF.AREA, SAMTARY 'Y N_
,• __— e RECEIPf a
RKMAN COMPENSATION DE[LAR TIO FIXI`JRpS PER TRAPSCHOOL TAX Y N
❑I hereby affirm that I have o certificatesomenc of consent to opytnsare,ora RECEIPT#
3800certir'cate Lab Ct Workers'Compewtlonlreurance oracertltled ropythereof(Sec, - ' GAS FA.SYSTFM4 INCA OUTLM , Tf�v PARK FEE Y . N
Policy If GAS EA.SYSTEM-OOVER RECEIPr#
Com any' BUILDING DIVISION FEES
[�Ce i!fic copyls hereby(uml,hed. GREASE/INDUSTRL WASTE INTERCEPTOR, PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
I, COMPENSATIONINSURANCES SEWER-SAMTARY-STORMEA.200FT. Dale Reccl IN
(rhi.section neednet bs completed if the permit ls(crone hundred tlollare
WOO)°rless.) WATER HEATER W/VENT/EDCTR ENERGYFEE Y N
I certify that In the performance ofthe work forwhich this permit Is issued,
I shall not employ any person in any manner so u to become subject to the WATER SYSTEM/TREATING
Worker.'Compensation laws of California. Date a.0 PAID -
O Z Applicant NEW RE9DLNT[AL PLMR SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you .
should become subject to the Workers'Compensation provislom of the Labor TOTAL:
~ W Cade,you=at forthwith comply with such provisions orthis pamdtahall be a
deemed revoked. BUILDING FEE /r�
OV
dCONSTRUCHON LENDING AGENCY SEISMIC FEE
I hereby affirm that there ls a construction lending agency for the perform ELECTRIC FEE p
Z ani,ofthe workfor which this permit is isseed(See.3097,Civ.C.) TOTAL: XO'D
02 Lender's Nana - , PLUMBING FEE fib- 0
u. - Lender'.Adama, QTY. MECHANICAL'PERMIT. FEE "' MECHANICAL FEE
OW Icerti(ythatl havereadthlsappliall....d damustme.ammnformation -
1 Is correct.Iagree to complywlth all city and county ovlleances and nate law. PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this -
F_ Z city to enter upon the abovcmentiomd property for Inspection purposes. ALTER OR ADD TO MFCH. -
(We)agree to save,Indemnify an d keep harndem the City of Cupertino — I Date Receipt#
V against liabilities,Judgments,crstsand expenses which may in anywayamme AIR HANDLING UNIT.(I'010,()OO CFM) SUBTOTAL:
Malrotsal4I_ iTconsryuenceof the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SlgmuunE. Appl nt/Centrad., Y' Date EXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
•• AZARDOUSMATERIALSDISCLOSURE
Will the appileant orfumer building occupant store or handle hacardous HEATING UNIT(TO IDgWO BTU) - Date Recei t#
material es defined by the Cupertino Municipal Code,Chapter 9.1$and the
Ilealth and Safety Code Section25532(a)2 I - HEATING UNIT(OVER 100,000 BTU) TOTAL: U Q
CI-Ye. MN.
Will the appllcantorfumm building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamedou,atrconuorhontseas de0ned bythe Bay Area Air
Quality Management District? BORER-COMP(3II'OR IOD,IXp BTU) -
Ye. ' MNo
have read the hMus materials requirements under Chapter 6.95 of', BOILER-COMP(OVER 100,000 BTU) ' APR
V 9
the California Health k Safety Code,Sections 2550.5,25573 and 25K
534.1
understand that if the building does not currently have a tenant,that it is my NEW'RESIDENTIALMECH. SQ.F7.
responsibility to notify the occupant of the requirements whtch must be and
prior to issuance o(a Ccrtificatc of Ottupanry. - city d CUpef4rR
Owner or auth°rived agent Date
TOTAL: ISSUED 3Y:� W' yautD
OFFICE COPY