22609 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulletin Pro ed Identification - PERMIT NO.
gildingAddress: 22609
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re a one
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oa CITY OF CUPERTINO-BUILDING DIVISION 18—n
C traders y LIc.N APPLICATION / PERMIT
BUILDINC-ELECTIUCAL-PLUMBINC-MECHAMCAL CATEGORY CONTROL
19- Archled/Engineer. o:
At-
e.
T QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1 G. hs (Z PERMITISSUANCE
LICENSED CON ACTOR'S DECLARATION 2� El
Ihereby affirm that l am licensed under provisions of Chapter9(commumc. APPLIANCESRI3STDENTIAL JO DESCRIPTION
Ingwlth Sed1on7000)of Divtslon3pfthe Budnesa dPm(esdonsC m,and my �7
I=Is full fc and d(ed. PANELS `'p� ('"Jr��a+ LL1�.--�s���\
License Chu Lordr ^� v `�—
Date Contractor
AACHITE A 201-IODDAMPS
1^re0ZO❑ I understand my plans shall be used u eco
public rrd' � , OVER1000AMPS SQ.FF.FLOOR AREA $/SQ.FF.
m 0 u Licensed Prefeulowl SIGNSELECTWCAL
<kqu
OWNER-BUILDER DECLARATION ` SPEGIALCIRCUIT/ML9C q � E D
Z l., Thereby a(Omn that l am exempt from the Coat.dors Lima.Law for the
9.qqqq following mum.(Section 70315,Business and Professions Code:Any city or
F� county which requbrea permit rocoaamaxt,alter,Improve,demollsh,areepalrTEMP.METER OR POLE INST.
ffffilililil any structure prior to Its a nutance,aLw«quires the applicant far such permit to O POWER DEVICES c. file a signed statement that he h licensed pursuant to the provisions of the
�OSContrador's License Law(Chapter 9(commencing with Section 7000)of DIv1-
don3 of the Business and Professions Code)or that he is exempttherefromset SWEdh9NG IDOL ELECTRIC E A
<, the balls for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURE9
applleanl fora permit aub'�chthe applicant to a tivil penalty d net mors than
five hundred delta.(S500). NEW RESIDENTIAL ELECTR
�a ❑I,as owner of the property,or my employees with wages as their sok __SQ,FT, STORIES TYPE CONSTRUCTION
compensation,will dothe work and thestmdure is not Intended or offered for
D sale(Sec.7099,Business and Professions Code:The Contractors License law
5$ does not apply to an owner of property who Wilds or improves thereon,and OCO GROUT' RFS.UNITS
who docasuchworkhlmulf orthrwgh Meownemployees,provided thatsvch
Improvements are not Intended proffered for safe.If,however,the building or TOTAL;
Improvement lasold within oneyearofcompldbn lheowner-WBderMll have
tl4j?urden of proving that he did not Wild or improve for purpose of sale.). (yry- PLUMBING PERMIT FEE RA)DD ZONE APN
I_f L as owner of the property,am exclusively contracting with licensed p 1T LS+UANCE
contractors to construct the project(Sec.70K Business and ProfessionsCode:
The Conteddoes License Iaw does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon, and who contracts (or such ptojects with a FEE SUMMARY
cgN(actor(s)B« rsua
need punt to the Contcadars License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B 4 P C for this «aeon
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N OUTSIDE
Owner Date BBC=#
WORKMAN COMPENSATION DECLARATION PER TRAP SCI 1001,TAX Y N
❑[hereby affirm that I have a artificah of consssu
nt to self-Inre,or a FD(TURFS RFLER'f#
cedlflIAb of Worken'Compeuatlonlnsunn««a«rilfled copy themrof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
Policy If CJ PARK TEP. Y N_
EIPT N
Calmcy n CAS F.A.SYSTEM-OVER C( A) DINGDIV
Y BUILDING DIVISION FEES
Certified copy Is hereby te
Certified copy h Ned withh the city
Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE $EWER-SANITARYSIORM EA 200F7 Date RC i t#
(This section need net be completed if the permit is for one hundred dollars
(5100)«lass3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
l amlfy that In the perfmaun«ofthework forwhlch this parnit is leaded, —
I shall not capi.y..y person In any manner eo u bent ab' to the WATER SYSTEM/TREATING
Workers-C rise Cal":.Ia.Data
rP X� 4 PAID
O Z A Ilcanll_ f' P..n NEW RFS(DENTIAL PLMB. SQ.FT. Dale Repel t#
Z O NOTICE TO APPLICANT.$after making this Certificate of Exemption,you
should become subject to the Workers'Compensatlon pruWlons of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
] decreed revoked.
'a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE (yy
an of the work for which this permit is issued(Sec.3097,CIv.C.)
r) O =de,'.Name PLUMBING FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcartifythatl M1avereadehbepplicatlonand statethal theaboveleformatlon
1 hcortect.Iagree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
).. N relating to building conetruchreu enta
ogand hebyaathotl «presdvesofthis
I— etytoenterupontheaWve-mentioned propedyfur Impaction purposes. ALTER OR ADD TO MECH.
U) Date ReCei t#
V — (We)a e to save,Indemnify an d k«p harmless the City of Cupertino
Iran
Ila litles,jdgme costsa xpenseswhichmaylnanywayacaue AIR HANDLING UNIT(TO 10.000CPM) SUBTOTAL:
) a teal City In con caoft granting of this permit AIRHANDLINGIINFF(OVER 10'"CFM) CONSTRUCTION TAX
Sgn rco Appilcant/ ontrador Date EXHAUSTI(OOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the app0ont or future budding occupant store or handle hazardous HEATING UNTT(TO 100,000 BTU) Date RCCCI f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: l O
❑ Yea No
Will the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eat hazardous air coma Mnante as defined by the Bay Area Air
. Quality Management District? BOILER-COMP QHPOR 100,000 BTU)
4 Yes IRNo
Y'.
read the huei.l'ous nuterials requirements under Chapter 6.95 of BORFRCOMP(OVER 100,000 BTU) lkA�•�t
the Calife role Health k Safety Code,Sections 25505,25533 and 25531. I
u ad crate ad that if the building does not corrently have a tenant,that It is my NEW RESIDENTIAL MECii. SQ.H7
responsibility to notify the occupant of the requirements which moat be met
prior to issuance of a arificate ofOcoupancy.
Owner or authorized agent Data
TOTAL: ISSUEDtl .
OFFICE COPY