22649 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Poo'ect IdenRficatima PERMITNO.
Building Address: �,� 't GP.ct-�t-�-� V27 22649,
LoneerName:A_ ane: A A
it Ppr 2TAT .A 7e, CITY OF CUPERTINO-BUILDING DIVISION - -
Contractor'dNamowwe: Lic.No: APPLICATION / PERMIT
A tett/En r. BUILDINGELDCTRICA PLUMBING-MECHAMCAL CATEGORY CONTROLX
Lk.Na
QTy ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: D S PERMITISSUANCE 0P r-sy' ISI ;
LICENSED CONTRACTOR'S DECLARATION /��
I hereby affirmthatI am lesseed under provisions of Chapter9(commenc. APPLIANCFSRESIDENTAL. ]OB DESCRI'HON
Ingrith Se on70t0)of Divlelon3ofthe Buslnessand ProfenionsCodeend my
license Is In fuI force and effect. PANEL'S I T
'T'
License Clave Lk.X l uL�-•)
Date Contractor UP TO 2DO ANTS
XII IOOOAMPS
ARCHITECTS DECLARATION
q�+02 1 understand my plana shall be used as public records
OVER AMPS SQ.Fr.FLOOR AREA ' $/SQ.FT.
ti Iy Licensed Professional SIGNSELECTRICAL
GG OWNER-BUILDER DECLARATION Ll c ISS DU
R �,C
SPECIAL CIRCUIT/MISC r` - 11Y IIVR G
There a(Brmthatlam exam fromthe Contractor's License law lw the I�{n+
Z02 F 9 following ichreq(Section 7031S,6mtl c and
r, fpmlons Code:Any city it tl V a
ceuntywhkh requires.pemNtrocorotruc5 es themprovq applicant forsuch,or to
TEMP.METERORPOLEINST.
.n any stredure pootaterooits ha he Es also sed pursuantttherovistordofpermit e
file a signed statement that be b licensed pursuant to the provlslora of the ' POWER DEVICESn TE
��EE55 Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divi.
�0 cion 3 ofthe Business and ProfessionsCode)or that he U exempt therefrom and SWIM3,ING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70313 by any
roomOUTLETSSWI'ICHESFI%TURES L O 1 /1 �J Q Qpr OQ
O applicant fora permit subjects the applicant to a civil penalty ofnot room than 61 [J
flue 1,as o nerdolof heSOD). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages m thele dole
compensation,Will do.in.g work,and the stCodom Is e:TheC ntractInteneoicansed for
Law
dale(Sec.apply
to alnow end f property
Code:The or impresses
Liceron law
does not apply torn owner offprough who builds nempoyde,provided
OCC.GROUP RES.UNITS
and
whodoementssuch sum cut Intendedlf hroffered own�.If,ho ea,p however,
thatsuch
Improvementsarenotintended earodco for sale.If,however, flder ill have TOTAL:
Improvement laeoldwithin oneyeara(tomplctbn,the owner-W Bderwlll have
t rden of proving that he did not build or improve for purpose ofmis.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
I �,
contractors to construct nruct the project(Sec.7044,Business and Professions Code: l -
The Contractor's License Law does not apply to an owner of propnty who
Wilds or Improves thereon, and who contracts fee each pWjetes with a ALTER-DRAIN As VENT-WATER lEA)
ogN(actor(s)Icenaed pursuant to the Contractor's License Law. FEE SUMMARY
Lj I am exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE I OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COM3. SANITARY - Y N_
Owner - Date RECEIPT X
�• WORKMAN COMPENSATION DECLARATIONve FIXTURES.PER TRAP /pr SCHOOL TAX Y N_
❑I hereby affirm that I haa cortiRote of consent to self-ince,ora RI Y RECE T X
certificate of Workers'Compereation Insurance or a certified ropy thereof(Sec.
3800,Lab CJ GAS EA.SYSTEM-1'INCA OUTLETS ..v� PARK FEE V_ N_
fL�
RECEIPT X
Ca X GAS.E1.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES '.
rlCertNed copy Is herebyfamished.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE X'
❑Certified copy is hfilod erebyith the city inspection dlvlNon. e W
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP - PAID ,
COMPENSATION INSURANCE SEWE&SANTfARY-STORM EA.200FT. Date Recei I#
(Chissection need not be completed if the permit isfor one hundred dollam
(S100)mIms.) WATER HFATEIt w/VENT/ELEC7R ENERGY FEE Y N
ce .
I rtifythat In the performance ofthework forwhlch this permit is issued, T
I shall not employ any person in any manner so as to became subject to the WATERSYSTEM/TREATING PAID
Workers'Compereation Laws of California.Date
Applicant —SFr. Date Remi t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of ENEW xemption,you RESIDENTIAL PLMB.
should became subject to the Workem'Compematlon provisions of the Labor t TOTAL:
Cr ; Code,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE
W > deemed revoked,
G CONSTRUCTION LENDING AGENCY SEISMIC FEE `
CL HurebyafBrm that there is a construction lending agency for the perform TOTAL: 4'1ELECTRIC FEE
M Z anre of the work for which this permit U Issued(Sec.3097,Civ.C3 �3
V O Lender's Name PLUMBING FEE
H Lemice.Addrem QTY, MECHANICAL PERMIT FEE
LL MECHANICAL FEE xCD
O W Iced.Ia tl agree to
eread comply with
allrcitionand dcou ty ordinances einformation
IL ctcorrect.]agreeto comply with ailtltyreby authentic,
repageandntat gate amofaws' PERMIT ISSUANCE FEES PAID:
N relatingto
rupont coratroctlontioned herebyyety fm In reprssenpurposes. ,
F city Mr)
ree to the abovcmenlloned property for Inspection purposes. I . ALTER OR ADD TO MECH.
? (We)egret m cove,IMemnlfy an d keep harmless the City of Cupertino ` Date RCCe1Pt#
V agalea llabWties,judgments,sonans expenses which may in anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
ago Ira Id Cityenceofthe granting ofthis permit.
�y p�lMR HANDLING])MT'(OVER l0000crM) �� CONSTRUCTION TAX
oefiqbgrata of AppR tCastad.r v Date 1 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appbrant or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date RCCeI [#
material a.defined by the Cupertino Municipal Code,Chapter 9.17,and the
Hc.It,and Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: S
El Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air contaminants as defined by the Bay Area Air
lity Management District? gOEER-COMP DEEP OR 100,000 BTU) sfA1 j� ry
Yea l�I No
Ihaveread the th&Safety
materials ode,Sections
2555,25533
553 aChM34..95 of BOILER-COMP(OVFR 100,00081L) Q •
theerstandt Health&Safety Code,Secturently1have a3and15534.] LJ p
understand that if the notify the ing occupant of to currently havewh ichpthat b iset NEW RESIDENTIAL MECH. SQ.[•T w+
responsibility ce notify the occupant of panty.requirements which must be met yX�y M
priorto imuanre of Certificate of Occupancy.
Owner or aulhorlaed agent Date
TOTAL: ISSUED
OFFICE COPY