22750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIRMITNO.
Bothell EE Address: /1^I�r 0
8 sot q13-1L113 G G l
Mra .mr: t one:
t t 1 009 CITY OF CUPERTINO-BUILDING DIVISION Q
C° tret ' NLIc.N° _ ��
l�I
Archltett/Engineer.
BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL X
APPLICATION / PERMIT
Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERMUISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffbm that am licensed under pmwdJ.na°f Chapter 9(rommene APPLIANCES-RESIDENTIAL JOB DESC a770N
Ingwlth Section7000)ofDlvblon3oflhe Bushessand Pmfes,lonsCodo,andm a
Brenn is In fu free an effect. 5a �. PANdS a 1061,l
DataLicess Llc p t!
Data CHITECr
UP TO 20OAhVS
ARCHITECTS DECLAR ION OVER00 AMPS
ce0 ZO I undenland my pion shall be used u public records. OVER 1000 AMIaS SQ.FI.FLOOR AREA f/SQ.FT.
ILL� Licensed Pmfessionl SIGNS ELECTRICAL
I6 OWNER-BUILDER DECLARATION
n
Zs- ' Thereby affirm that[cent exempt fmmthe Contractor's License Gwfor the SPECIALCIRCUIT/MLSC
Q '
O fallowing trader. Business and Prons fenluCode:Any city or
F F'� rountywhichrequbesapermittororotr d,alter,lmpnve,demollah,orrepalr TEMP.METER ORIOLE INST.
q°'I anystructum priortoltsbwance,also requlreathe applicant forsuch permit to
tee`cG s file a signed oarsmen that he Is licensed pursuant to the provisions of the POWER DEVICES
w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
OQ slop 3 oflh.B.dress and Promeslons Code)orthel he le exempt lhemfromand VALUATION
•.1 the basis for the alleged exemption. Any violation of Section 70313 by any �,a—a 0 D
Applicant fora perrrdt subjects the applicant to a civil penalty of net room ban OUTLETSSWITCHESHXTURES
(��/xf['1•v)
pQ� five hundred dollars(f5110i.
�"n Las owner of the property, NEW RESIDENTIAL ELECTR-_SQFf, STORIES TYPE CONSTRUCTION
7�n ❑ p ork,a or my employees In of Intended wages as thele sale
or
aak7,.7d wllldothew Pmric toes Code:Tbn Contactor or im..L w
ale(not.p 44,to alnow and(prop�oau Code:The or improves
Ucerue Law
�,I 3 don not apply to rk owner or property who n Ild.or Improves thereon,and OCC.GROUP RES.UNITS
CK: whod°em nts am kMmsededoroffe d own�.If,
hoeever,t ebuddtsuch
improvementaarenotintendneyearfe pl utathemer-buflebulWih.ve TOTAL
Improvement btold within one yea rorcompielloq the ownenbu0derw111 Fuve '
t1 .Burden of preving that he did not build or improve for purpose ofsele.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the Property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the pm)ect(Sec.7044,Business and profession Code: PERMIT ISSUANCE 16,UO The Contractor's License Law dme.not apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
builds or Improves therece,and who contract. for such ptnjects with a
onactroW licensed pursuant to the Contractor'.Lla^ee Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reawn
DRAINS-FLOOR ROOF,AREA,CONTI. SANITARY Y N_
Owner Dale RECENT'X
WORKMAN COMPLNSATION DECLARATION FDCURESS PER TRAP SCHOOL TAX Y N_
LjjWhemby affirm that I have.netiflats of consent to self-im.m'or RECEIPT X
certificate of Workers'Compenatlon Insurance or a candied copy thereof Csrc. CAS PA.SYSTEM-1 INCOUTLETS
3800,lab C.) PARK PER RECENT M
P°Iirya wey7no�z- 1 GAS-eA.sYsrEM.ovERa(Ea)
fi
�r^ BUILDING DIVISION FEES
Cert^ Y lfied copy I.hereby the e cie city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Ified copy b filed with th
CERTIFICATE.OF MMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(TFlasection need net becompleted lithe permit bforone hundreddollan SEWER-SANITARY-
STORM B.A.200FI. Date RC i t#
(5100)orlcss.) WATER HEATER W/VENT/ELECTR (,, ENERGY FEE Y N
Ill net that o the person
i any he mar e,for to become
permit b issued,the ;J —
I shall mol employ any Laws f any manner ao as b become eubjett to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Data. PAID
0 Z Applicant Date Recei t#
Z O NOTTCETOAPPLICANT:lf,aftermakingthb Certiflateot Exemption,you NEW RESIDENTIAL PLMB. SQFI.
should become tubPo to the Worken'Compe—tion pmvblon of the Labor TOTAL:
C N Cade,you most forthwith comply with such provisions orthb permit shall be BUILDING
7 deemed revoked.
LU
C CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there b a construction lending agency for the perform- ELECTRIC PEE
Z assn of the work for which this permit is issued(Sec,3897,Civ.G TOTAL:
02 Larders Name PLUMBING FEE
LL h Lender's Adders, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlrythat l have mad lhbappliatlonand.tatethat lheabove Information
a bconect.I:gree to comply withal]cityand county ordinances and state laws PERMITLS,UANCE FEES PAID:
>• W relating to building contomtion,and hereby authorize representatives ofthis
~ Z city to enter upon the above-enodloond property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indeermly an d keep harmless the City of Cu Partino Dake Rece) t#
V
against liablllties,judgment nd expenses v ichmaylnan ways a AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL'
aga 1 City In con th gr'ming oTS,his perm
fokv AIR HANDLING UNIT(OVER 10,000cn4) CONSTRUCTION TAX
of Ap t/c nracta D,n EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllaracefuture building occupant store or handle hazardous HFATINGUNIT(TO100,000131711)
material.,dullard by the Cu�rtlno MuNrlpal Code Chapter 9,12,and the Date Recei t#
Health.nd Szfcty Cade,Syeffno 15532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yea No �(
Will the applicant or future bu ding oavpanl use equipment ordevicea VENTILATION FAN(SINGLE RESID) 1'_ DATE
which emit haurd°u.atr con name asde0nedby the Bay Area Air tYE
Quality Management D-todf IIORER-COMP OHP OR 100,000 BTU)
I Yes Na SEP .214 1551
havereadlealth& outmuterlois requirements undaChapter495 of BOILER-COMP(OVER iW,000 BTU)
unthe Califersta dthealth building
Code,S tela 15505,25533and15534. I
understand that i(the buildingdon not currently have atenanL that ltbmy NEW RESIDENTIAL MECH. SQ.FT.
Inporuibility to nmify the o.pant of the mqui em.tee which most W mel cupedion
prior to issuance of a CertiOate of Occvpanry.
Owner or authorized agent Data ISSUE BY:
TOTAL:
OFFICE COPY