22496 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingPro'et ldmtlHcaUon ,ts D PERMIT NO.
Bzo Add v v e e� ,� 22496
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TBefi HI l ZS$—�zS'liCITY OF CUPERTINO-BUILDING DIVISION
Contrator'e Name: Lk.No: APPLICATION /PERMIT _C
BUfLDINGO.ECTRICALPLUMBINO-MECIIAMCAL CATEGORY CONTROL If / /
Architect/En n Lie,No: WP
Lie,
pp QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: OD C Lr� O<t. C6 YJCOY PERM] ISSUANCE
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
Ibcmbyafflrm that lam licensed under provilonsof Chapter9(comment- APPUA CES-RESIDENTIAL JOB DFSCRUFION
Ingwith Section7000)of Dlvlalon3 ofthe Buslnessand PrufessionsCode,and my
license Is in full force and effect. PANELS ���-++wr��}}}����^ -y—
Date Lic.# or l ` V
ARCHITECTS DECLARATION 20t-1000 AM
q 2 I understand my pins shall be used as public records. OVER 1000 AIS .1j�PILS EAD FT.
q��++ ❑O❑ „„
k z U Licensed Professional SIGNS ELECTRIC as ,.
<Qµ OWNER-BUILDER DECLARATION 1„v/1, U
�n Fn vSPECIAL CRRCUIT/M
I_ � Ihemby,(Osco that lam exempt from the Contactors License the
TE
ZO 2 t- following reason.(Section 7m15,Business and Professions Code:Any city or TEMP.ME LER OR POLE /
counlywhich requbt
esa permit tocorstru ,alter,improve,demolish,oreepafr TIS
qmm anystructure,prlortolts Issuance,aiorequires the applicant forsuch permit to ROWER DEVICES
Pi o; 1 file a eigrM statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter9(commencing with Sechon7000)ofDivi. SWMWNGPOOL ECTRIC VALUATION
O Id n3ofthe Busincssand Profeslors Ccal0orthat heiexempttherefromanci
the basis for the alleged exemption. Any violation of Section 7MI5 by any /-
�65
applicant for a permit subjects the applicant to a civil penalty a not morethxn OUTLETS-SWI aQO�. �O
µ five hundred doll..(S50N. NEW RESID AL ELECTR .FT. STORIES v TYPE CONSTRUCTION
/¢ F-11,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is not intended or offered for
$ o sale(Sec.7044,Business and Professions Code:The Contractors License law
$$ does not apply to an owner ofproperty who builds or improve,thereon and OCC.CROUI' RIS,UNITS
whodoeauchworkhimseBorthruagh Msownemployees,provided thatsuch
Improvements are not Intended oroffered for sale.If,however thebuilding or TOTAL:
improvement iasoldwithlnomyearofcompldion,theowner-builderwill have
the,*rden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
Ll I,as owner of the property,am exclusively contracting with licensed IT ISSUANCE
to construct the project(Sec.7044,Business and Professions Code:
PERM.The Contractor's License law does one apply to as owner of property who ALTER-DRAIN AVENT-WATER(FA)
Wild.or Improves thereon, and who contracts (a such p(ojects with a FEE SUMMARY
co tt(actor(e)Ilansed pursuant to the ConlractoreLkenx Law. BACK W PROTECT.DEVICE
LII am exempt under Sec B Is P C for this reason
OUTSI DE FEES
DRAINS. R ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECERxTM
WORKMAN COMPENSATION DECLARATION FIXTURES.I TRAP SQiODL TAX Y_ N
Of hereby.fNm that 1 have a l rt ane of consent m pytheu l'or RECERxT#
artiflate of Workers Compcwtlonlnsuranaaacertifled copy thereof(Sec. GAS EA.SY -I INC<O S PARK FEE Y N
3800,Lab CJ REC=#
1'ollry# GAS EA.SY VER4
Com any BUILDING DIVISION FEES
�Certlfied copy is hercbyth thehed. GREASEANDUSIR WA INTERCEPTOR LANCHECK FEE
❑CediOed copy b filed with the city Inspection division. /
CERTIFICATEOFECEMPTION FROM WORKERS' GREASE TRAP PAID I O ]
COMPENSATION INSURANCE SEY✓FR-SANITARY- EA 2oarT Date RCCCI t#
(Thi section need not be completed if the permit is for one hundred dollars
($1W)orless.) WATER HEATER /v /F3-ECTR ENERGY FEE Y_ N_
I cortftythat i the performance of the work for which this permit Is issued,
1 shall not employ any person In any manner so as to become subject to the WATERSY TRFATI
Workerd Compc.xxIkn Lawsof Caldomi. Date PAID
O Z Applicant NEW READ LI'LMB, Date Recei t#
Z U NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
cc N Code,you must fort hwith comply with such provisions or this permit shall be BUILDING2.V 0
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE I/
CL Ihereby affirrethat there iacosutruction lendingagency forthe perfomxry TOTAL: ELECTRIC FEE
M Z an ce of the work for which this permit is Issued filer.3097,Cie.C.)
() O (.enders Name PLUMBING FEE
L F Iender',Addmss QTY. M CHANICAL PERMIT FE MECHANICAL FEE
U I cortilythat l have read this application and statethatthe above Information
O W icorret.lagrectocomplywlthalldtyandmuntymdiancesand state laws PERMIT I ANCE FEES PAID,.
} O' relating to building consuuction,and hereby authorize representatives of this
F. z dtyto entcrupon the above-mentioned property for in,pe tion purpose. ALTER OR DD TO MECH. Date RCCCIPt#
_ CWe)agree to save,Indemnify an d keep harmlee the City of Cupertino AIR HAND G I1M7(f01 , CFM)
against liabilities,judgments,cosm.ral expenses whkh may in any wayaccrue SUBTOTAL:
ago Inst said City In consequence of the granting of this permit ONSTRUCTION TAX
AIR FIANDLI GI1MT ER t0,f1DOCFM)
Signature of Applicant/Contractor Date E%HAUSTH /DUCT) CONSTRUCT ION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
III` Will the applicant or future building occupant store or handle hazardous HEATING UN TO 100,ODO BTU) Date RCCei t#
outerlal as deBocd by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATIN MT( VER 100,000 BTI) TOTAL: D�
❑Yen L�No
Will theapplicant or future bcildingampart use equipment or devices VTIONPA INGLERESID) ISSUANCE DATE
which emit harardous air contaminants..defined Airby the Bay Area A
Quality Management District?No ER-COMP pFm OR 1 W,IX10 BTU) *Vowlwl
Yes No
have read the hazy ous materials requirements under Chapter 6.95 of ILER-COMP(OVER 1 K”BLU)
the California l lealth A Safety Code,SM loss 7550.5,25533 and 25534.I �
understand that if the building does not currently have a tenant,that it i my RFSIDENTIALMECH. :Q.FT. AUGA
responsibility to not ify the panto ftherequirementewhichmustbemet
prior
ndLSeVja tl' teo Oaupanq. ^IZq/a 1 W-
I �
O.b(ior author red�agent /'Date 1 ISSUE
TOTAL:
OFFICE COPY