22335 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PERMIT NO.
o Building Address:
22335
sur �s�
wnsrsy ta,ntae:
'//l tLtl�sa.o , S• �J�2 CITY OF CUPERTINO-BUILDING DIVISION
c.ntractor Name: Lie.No: APPLICATION / PERMIT 1
2cr -JS BUILDINGELECTRICAT PLUMBING-MECILAMCAL CATEGORY CONTROL
Architect/Engineer. LI,.N.
QTY ELECTRICPERMIT FEE BUILDINGPERMITINFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hercbydfirm that l am L'censed under provisions of Chapter9(commenc- APPLIANCESREBIDENTIAL JOB DESCRIPTION
ingwlth Sedion7000)o(Divisim3ofthe BuMns and Professions Code,and my
license it,In fial,fors and died. PANELSUPTO
l ,
LlraneeChee_' LIC Y+�� fid./11
Date Cco rector /d cL-�2^� 701-1000 AMPS
AMPS
ARCHITECTS DECLARATION
pkv O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR'AREA SM.FT.
kb Licensed Professional S'IGNSELECTRICAL
Z A L E D
6 OWNER-HOLDER DECLARATION
I hereby afflrmfrom the I am exempt frothe Contractor',Llsne Law for the SPECLALCIiCU1T/MLSC
0pfollowing reason.(Section 70315,Business and Professlore Code;Any city or TEMP METER OR POLE INSf.
P p county which requires a permit to construct,alter,Improve,demolish,or repair COMPUTE
1Q15 any strvctom prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
K�il file a signed statement that he Is licensed pursuant to the Provisions of the
mµ1- Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
f, OJ stars 301 he Buttress and Professions Cod.).,that he iswompt therefromand
Q the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWI7CHFSFIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
1pp1� five hundred dollars(5500).
n1,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FL STORIES TYPECONSIRUCTION
compenution,willdothe work andthe structure 0 not intended or offered for
Oels(Sec.70K B oche.and Professions Code:The Contractors License Law
3$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who docssuch work himself orthrough his own employees,provided that such
improvement are not intended oroffered for sale.If,however,the bu old Ing or TOTAL:
Improvement Is sold within oneyearofcomplHbn,the owner-budderwlll have
tta.kurdan of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.70K Busloom and Professions Code:
The Contractors Licene Law does not apply to an owner of property who ALTER-DRAIN At VENT-WATER(EA)
bsllds or Improves thereon,and who contrera for such pkajecta -
with a FEE SUMMARY
cootractor(s)Boomed pursuant to the Contndtor'e License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B k P C for this reason
OUTSI DE FEES
Owner Data DRAINS FLOOR ROOF,AREA,CONED. SANI'T'ARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT p
�{1 PIX'IVItFS PFR TRAP SCHOOL TAX Y N
hereby affirm that I have a certlfiate of consent to self-Insure,ora
s" flute of Worken'CompevaHonlesuounce ma snlfkd ropythereoft5ec. RECEIPTN
3500,TabJ` GAS EA.SYSTEM-1 INCAOUTLETS PARKFEE Y_ N—
,it N_�L(l C d'7r9O�.Z"' � GAS EA.SYSTEM-0VER<(EAI RECEIVE M
Com any _(,...i�il6.✓ �___n_ - B UILDING DI VISION FEES
ertlRed copy I.hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with the city inspection division.
C.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.700FT. Date Reel t#
(Thos section need not becompleted',(the permit b forone hundred dollen
($100)otIfyth WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
[mrtlfylhst lethe pedormansa(the work forwhkh this permit is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING PAID
Worken'Compensatbnf�wsof California.Date
O Z Applicant NEWRESIDENTIALPLMB._�JFI'. Date Recel ted
Z ONOTICETO APPLICANT:If,after ma king this Certificate of Exemption,you
ahould become subject to the Workers Compensation provisions of the Labor TOTAL:
F A Cade,you must forthwith comply with such provisions orthis permit shall be
BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. Iherebyaffirm that there is a construction lending agency for the perform- o-Q ELECTRIC FEE
M Z ancoofthework
U O Lender',Name for which this permit is Issued(Sec.3097,Civ.C.)
TOTAL: PLUMBING FEE
LL E- Leadee.Addreat QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have mad thteapplfatlon and statethatthe above information
IL b :
comect.Iagrcemcomplywlth all cityand countyordlnanmand stall laws PERMITISSUANCE FEES PAID
>- relating tobulidingconstructlon,and herebyauthoteerepreentativesofthb
Zcity to enter upon the abovnmentlonet property for Inspection purpose. ALTER OR ADDTO MECH.
— (We)agree to save,Indm
enifyn d keep harmless the City of Cupertino Date Recel tit
againsHlabillticajodgmarts,costs..cimperam.hichmayinarywayaccrm AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL'
9g�Inst uld City In conaauenge of the gnming of this permit.
AIR HANDLING UNIT OVER IR0D0CFM) CONSTRUCTIONTAX
4P(gnature of A'ppUcantt/CCoonttrractor Date 7 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplcant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei ted
material as defined by the Cupertl an Municipal Code,Chapter 9.1 7,and the
Hr-1 Yard Safety Codon 25537G)7 HEATING UNIT(OVER 100,000 B
,OTU) TOTAL:
Will the appliantor mrebuilding.ccupantuseequlpmentordevices VFNDLATION PAN(SINGLE REBID) ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air p�QM
�usilty Management DbttlL17 BOILER-COMP DFI'DR 100,000 BTUI PM
j I Yea JRNo
TThNavorcaa ea hazJ�us Code,materobrciom underChapter and 25534.
1 of BOILER-COMP(OVER700,000 BTU)
theCaliforniaHealth building
Cods Stolons75505,ve.t and,that I X
'espomunderstandthat if thenotify
theonupant of
a requirmnts tenant,that b met NEW RESIDENTIAL MCCH, SQ,FT. 4� --
rnponslbllltytoof Ctheoccupant of the requirements which mutt he mel
P or to Lssuance of Certlfl tea JO Percy.�a�
�S ner or authorized agent Data ISSUED
TOTAL: 6Y:
OFFICE COPY