22179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'ect Identification PERMIT NO.
Building Address:
Lyes , w o�,=� �� 22179
eA A A
eaFwyQ OF UErr' CITY OF CUPERTINO-BUILDING DIVISION r
G %a ane: (LLlc..No,. APPLICATION / PERMIT 2-�y 1
f L'OUS /C Yc�I L BUILDINGELECTR[CA4PLUMBINGMECHAMCAL CATEGORY CONTROL M
i Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
Ihembyafflrm that l am licensed under provisions of Chapter9(commore APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Se<ton7(00)of Division 3ofthe Buslnessand Profession Code,and my
Ilrenx 1,In fuB form and effect. PANELS �^a("� CF
_� px
License Class LIc.8 V7 s�M"'1 J
Date Contractor UP TO 20DANU
ARCHITECTS DECLARATION 201.1000 AMPS
N CO I undrestand my plan shat be used as public record& OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
�Qo Li. ...dWProfessional SIGNS ELECTRICAL LED IN
6 ONERBUILDER DECLARATION P U T E R
< SFECIALCIRCIIIT/MISC
6,
F, Ihercby atOan We
that exempt from the Contractor's Llsnx Law for the
rg.a county hichmcuirectlonrmitS,Buslnex andafteProfessions Code:Any city or TEMP MEEK OR POLE INST. / ��'
county which reior to IsperMttomnrequ esth applicant
forsuch,orrepairmitto �^♦w
W8any structure priortolb issuance,also requlrstheappllant(orsuch permit to pOWFRDEVICFS DATE
tL file a signed statement that he b licensed pursuant to the provlslon of the
O` Commet.e.License aw(Chapter 9(commeneing with Section 7000)of Divi- VALUATION
O In SWNIMING 11�OL ELECTRIC
GG he basis
Budnes andPemptionC Any
of exempt therefrom and
pX'.a the Want for the alleged exemption. Any violation of Section net m re any O ry)
r G5 OUTLETSSWITCIIESFI%TURES B&l...t/
applicant(ora permit aub)mts the applicant to a dull penity of net nnre flus
o five hundred dollars($500).
�n ❑T,as owner of the roe NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
p p c,a or rtry employes with wages r thele sole
C compensation,B.Aresstrulwill do the rend th.Cc1urels nomaracdedorofine Lar
T�0 sale(Sec.70Cy Businna and PrMmbro Code:The Contractors Wcen+e W w
dos not apply to an owner of property who builds or improves thereon,and OCC.GRCUP RES.UNITS
E who doessuch workhimxlforthrough hisownemployees,provided that such
Improvements are not Intended oroffered fors tle.If,however,the building or TOTAL:
Improvement bsuld withmoneyearufcompletion,theowner-bullderwill have
th,e.,I,uedea of proving that he did not bund or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L-J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mntiuct the Project(Sec.7064,Business and Profenion Code:
The Contadori License Law does not apply to an owner of property who ALTER-DRAIN kVIM-WATER(EA)Wed,or Improve thereon,and who contracts for such p(ojects with a FEE SUMMARY
co ctor(s)Bernard pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
U[am exempt under Sec. B k P C for this reawn
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FIXTNTEq PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-ineure,ora RECEIPT N
mrtifiate of Worker Compenationlnuranm ora mrtifled copy themof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.)
RECEIPT N
Policy X GAS EA.SYSTEM-0VER 4(FA) BUILDING DIVISION FEES
Co any _
ffCc Met copy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
❑Certlfird copy is filed with the city Inspection division. Q� I �/�/�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ,-� Y Yl Qo / LI-�
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200F1' Date Recd t4tRa
(This section need nut be completed If the permit is forox hundred dollars
(S100)or lcv.) WATER HEATER W/VENT'/ELECTR It ENERGY FEE Y_ N_
I codify that N the perfamunm of the work forwhich tAls permit Is blued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESID=AL PLMB. SQ.FT. Date Revel tN
Z0 NOTICE TO APPLICANT.If,aher makdng this Certificate of Exemption,you
should become subFd to the Worker Comperoation provision of the Labor TOTAL:
F W
Code,you most forthwith comply with such provisions or this permit shalbe BUILDING 'B e 6
deemed revoked.
I1J — CONSTRUCTION LENDING AGENCY SEISMIC FEE I
a Ihereby affirm that there in a construction lending agency for the performELECTRICFEE
M Z anceofthewmkfmwhlchthbrmit peishoued(Sec.3097,CW.C.) TOTAL:
IJ O U.dera Name PLUMBING FEE
IL F I.ender's Address QTY. MECHANICAL PERMIT FEEMECFIANICAL FBE
OW 1c`rtlfythat l have read thbappliation and state thatthe above information
CL cornet Iagreeto comply with all city and county ordinances and gate laws PFILMITISSUANCE FEES PAID.
>. W relatingto Wilding construction,and hereby authorise roprexntmivs ofthls
Fcity to enter upon the above-mentioned property for inspection purposes. ALTINORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu Fortino Date Reeeiptri
V
against liabilities,peigments,cogs and expenses which may In any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agalnt xltl t neaqof the granting of this permit.
semP"'�F1
S, AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
'Sigo 'e of Applicant/Contactor Date IXIIAl1ET HOOD M,DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE I t�
Will the applicant or future building omvpant store or handle hazardous HEATING UNIT CFO 100,000 BTU) Date Recel tis
metrrbl as defined by the Cupertino Municipal Code,Chapter 9.17,and the
ITnllhand Safety Cede Section 25532(s)2 HEATING UNIT(OVER I W,00(1 BTU) TOTAL.
❑Ys 0 No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardum air contaminants as defined by the Bay Area Air
Quality Management DisMet7 BOILER-COMP QHPOR 100,000 BTU) `a'
Yes nn No AID,
�- 4havr read the haz.cls materials requirrments under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the Calitornla Health k Safety Code,Section 25505,25533 and 25534. I
understand that if the Wilding does not currently have atenant,that i[bmy h'LW RESIDGTIIAL MECH. SQ.F7 a-a
rspotaibility to malty the occupant of the requlremonts which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY;
'
OFFICE COPY