22617APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ad Idenunammn .a>
Itullding Address; V:„D,•C � iso -,v
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PERMITNO.,
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22617
nera � one
w I t• a o r,4er4bi-7ji.I3Q
CITY OF CUPERTINO-BUILDING DIVISION'
APPLICATION / PERMIT
A A
cnnt erre: Lie. No:
zy
BULDING-ELECTRICAI,M.UMBINGMrOl AMCAL'
a
CATEGORY
CON3jE0 F41
Arebitect/Engin a Lie No:
ELECTRIC PERMIT,�i t
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', ffCE 1
'.r BUILDING PERMIT INFO' - r -
Address: .'
. PERMITISSUANCE
t
❑
jek
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l are licensed under provisions of Chapter9(roernme,
althe Buslneaeand ProfesalonaCodc, and my
ingwnhSecten 7000) and effect.
license is in (uB( and effect
APPLIANCES -RESIDENTIAL
JOB DFSCRI'TION
-
PANGSCJh/
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cense Claes Lk. M O L
_ -
Dat Contracto j.
'
701-t000AMP5
ARCH ITECPS DECLA ATION
' Iundentend my plarushail be used as public records. ,
Licensed Professional - ^;`
OVER IOW AMPSFLO—C�,yRF�.
SIGNS ELECTRICAL
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E/SQ. Ff.4s�
SPC IALCIRCUT/M(��
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor. License Law for the
TEMP.MEITRORPOLEI
POWER DEVICES D
TE
following reason. (Section 7031.5, Beat.. and Professions Code: Any city or
outetywhlch requiresa permit neconatruct, alter, improve, demolish,orrepair
anystmcture prior to its Wuance,alo requiresthe applicant for such permit to
toe a signed statement that M b Bcenaed pursuant to the provisions of the
Contraeo/s License Law (Chapter 9 (commencing with Section 7000) of Divi-
ivi-
sion
slon3 of the Business and Professions Code) orthai he is exempteherefromand
the basis for the alleged exemption. Any violation of Section 7MI.5 by any
applicant for a permit subjects the applicant toe civil penalty of not merethan
/s
,a•A
L f ..,
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SWIMMING POOL ELECTRIC
_
OUTLETSSWITCHFSFIXTURES�Y'r
^ VALllA7A7O�N7
NEW RESIDENTIAL ELECTR . SQ.Fr.
five hundred
owner of the Oro
� ae owner lithe property, or employees with wages their sole
STORIES �
TYPE CONSTRUCTION
compensation, d hes or d for
the nd
ihesbucte:
ao
sae (Sec. and
sle &c. 44Business The C ntractIntenr' Law
Pr fes Code: The License Law
TOTAL:
-"
'!-
tow f property ds or impctale hemon
apply loanowner of or through his one morimprovnthereat such and
apply
who ddoes oes
whodoementsarerkhimselfedorofgh hleowne, It,ho ever, the s, providedbuilding
improvements intended doting or
I(, howeveplheerwill
OCC. GROUP
RES. UNITS
sold
ImprovementVsoldwilhinoneyearotcompletiarythe owner-bugderwlll have
earofredfortio, have
the hurden of proving that he did net build or Improve for purpose of sale.).
HL as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Professions Code:
t.-.,-, i
QTY., .'+�t�h, it PLUIViBINGtPERMIT'.l �I t
".th
':'•FEE':.
'
... FLOOD TONE
-
APN
PERMITISSUANCE
The Contractor. License Law does net apply to an owner of property who
Wilds or improves thereon, and who contracts for such princes with a
IN,eter(s) licensed pursuant to the Contractor's License Law.
am
am exempt under Sec B & P C for this reason
ALTER -DRAIN As VENT - WATQ2 (EA)
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t•54j1i�1'-jr'; FEE SUMMARY.'t'S"''
ROW PROTECT. DEVICE
DRAINS -FLOOR ROOF, AREA, COND.
F5
FD(TUR'PER TRAP
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SANITARY Y_ N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
T7, hereby affirm that 1 have a me l0cete of consent to self-inw
cenileme of Workem-Comperaation lraurnce or a mrtilled mpy themo((Sec.
3800, Lab C.) -
Policy MCAS
SCI100L TAX Y N_
REEEIPT a
GAS EA. SYSTEM-11NG40UTLETS
PARK FEE Y_'N
RECEIPT X
EA. SYSfEM-0VER 4 (FA)
-
Com any -
BUILDING DIVISION FT.ES
❑pCertlfled copy b herebyfurnished.the cid.
❑CenBed copy Isfiled herebyiththe city lrapecllan division.
CERTIFICATE OF EM PFION FROM WOR KERS'
COMPENSATION INSURANCE
(Thiaeactian need not ba completed If the permit le Corona hundred dollars
CREASE/INDUSFRL WASTE INTERCEPTOR
PLANCHECICFEE '
/
PAI�`p/`l
Date Recel t#
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i
GREASE TRAP
SEWER-SANTTARY-STORM EA.IW.FT.
WATER HEATER W/VENT/17,GCTR
ENERGY FEE 'Y N
($100)orleas.)
I certify, that In the performance ofthe work forwhich this permit is issued,
WATDi SYBTEM/TRGTING -
I shall not employ any person In any manner m m to become subject to the
Workers'Comp¢nsation Laws of Calilomia, Date
1Y
P V
ApplicantNEW
NOTICE TO APPLICANT: If, after Puking this Certificate of Exemptlan, you
Date Recti t#.
RMDENTIALPLMB. SQ.Fr.
TOTAL:
should become subject to the WorkerCompensation proveloro of,he Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING FEE
-
SEISMIC FEE -
a a
CONSTRUCTION LENDING AGENCY -
liumbyafflrm that them iso cumwctlon lending agenq (or the perform
anmoftheworkfor which this per cot is Issued(See. 3097, Civ.C.) .
Lender's Name
Lender's Address
' . I cenifythat 1 have madthis applicationand statethatthe above information
Is correct.I agree to comply with all cityand county ordinances and state laws
- TOTAL:
�'
ELECTRIC FEE
l
-
QTY. MECHANICAL PERMIT'.
..
.� FEE
PLUMBING FEE
MECHANICAL FEE
PERMTTISSUANCE
ISL®
FEES PAID: ^
relating tobuilding construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Wpectlou purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against lis es, ludgrnens, casts and expenses which may In anyway accrue
Date ReceiP1#
ALTERORADDTOMECH.
a
La�-
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
eget t d Ity In consequence he nting of this permit.
- AIR HANDLING UNIT (OVER IO,000CIiM)
CONSTRUCTION TAX
�gwtureof rat/Contractor Date
EXHAUST HOOD M/DUCT1
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
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HEATING UNIT (TO 100,00) BTU)
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Will the applicant or future building occupant store or handle hazardous
material as defined by the CuNnum Municipal Code, Chapter 9.12 and the
HealthandSaletyCodet+.-S,ealon25537(a)7
r-1 Yes , u No
Date - ReceI t#
EA
HEATING UNIT (OVER 100,000 BTU
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TOTAL:
Q
VENTILATION FAN (SINGLE RESID)
_
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit baza mous air contanena nits as defined by the Bay Area Air
Quality Management District? _ '.
47 Ycs ' No
havareadthehazaYusmaterialsrequirementsunderChapter6.95of
the Calilomlahlealth&Safsty Code,Saions25505,25533and25534. 1
r
0C,I
{Z pp 7
V.rvOa7.
BOILER -COMP 0HPOR 100,000 ITU
BOMER-COMP(OVER 100,0MRM
EWRESIDEALMECA.. SQ.FT.
NNTI
understand that lithe building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate olOccupanry.
Owner or authodred agent - DateISSUED''B``Y::GG
TOTAL:
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OFFICE COPY