22393 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 22393 n^n
at 232.
6Gu�E2TiavGG�S/.9
d R � cu,o T, t,d 3
mrs ante: hone:
�}vi'D T)0-0-15 — CITY OF CUPERTINO-BUILDING DIVISION
Name: Lic.No: APPLICATION I PERMIT C�
Goal I L BUILDINCaMTRICAI PLUMBINC-MECHAMCAL CATEGORY CONTBOL,M�^'7
Architect/Englneer.e Lie.Na CD l0 I
/,7ays[/ G a( tff/9 afit'o,v QTY ELECTRIC PERM FEE BUILDING PERMIT INFO
AddreacPERhETI55U P
jA �• TSI
LICENSED CONTRACTOR'S DECLARATION hL]
I hereby affirm that l am licensed under provisions of immature. E L J08 DESCRB'IIODL.��Aa
Ingwith Section7OOD)of DiNsion3ofthe Buaneaeand ProfeseloneCodgandm
limnse le in full(o and d(M. t .Z1.44 — —J
License C_IR�q {��`�Lk.p�S-S I FG7�rSirii.
Date/ j�Contractor_D_� AP
ARCHITECTS DECLARATION
/\/\/ (((/// ��' 201-1000 AMI5
NO 2 I understand my plans shallbe used as public records. {� OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licensed ProSIGNSELECTRICAL
(emionsl 13�
�6�� OWNER-BUILDER DECLARATION gtF-C(pL CIRCUIT/M15C LL
IherebyafBrmthat l am exempt from the Contracte.License Lawfmthe
O q following resson.(5ecti.7011S,Buslneasand Professions Cade:Anydtyor �l
FZh'vt countywhich requires a permit romnstruct,alter,Improve,derealuborrepair TEMP.METER OA POLE INS(. I�
S51 a an ysmmmpdortoibbeuameaborcquirntheappUa tforsuchper tto POWER DEVICES6 p{ file a signed statement that he L licenced pursuant to the provisions of the
Cruractr'.LIccm*LAw(Chapmr9 coourencin with Section 7000)ot Diel-OVALUATION g don3oftheBudmmdProfrlomCode)°rthagheleemmpttherefmmand SWIMMINGIWLELECIR[C �� LUT2a
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHE4FIXTIIRES (,, �/
applicant fora permit subjeetsthe applicant to a dell penalty d na more than
tNc hundred dallan(5500). STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR_SQFT
pensation,willdothe work andthe structure Is not Intended or offered for
p sale(Sec.7044,Business and Professions Code:The Contractors License Law
�$ does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNITS
who doessuch work himself°rthmugh his own employees,provided that such
improvementsarenot intended omlfered for ale.ILhowever,thebuildingor Tl IV
'
improvement bsold withinoneyearolcompidion,theowner-bu8derw8l have
t ben of Foreleg that he did not build or improve for purpose ofaale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
�(I 4 ae owner of the property,am exclusively mntrading with licensed / PERMITISSUANCE �.�• '
tenders to mnsiruct the project(See.7041,Businev and Professions Code:
The Contractor's Liawe Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EN
builds or improves thereon, and who contracts fee such p(ojects with a
ctmW licensed pursuant to the Contractoe.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
„J I ec
1am exempt under SB k P C for this reason
Owner
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Yan IS
Dae RFG
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N_
C31 hereby affirm that I have•mttificate of concent to self-insure,oraFl) RFGFTPT x
certificate of Workers'CorepensaHon lnsuranmmaerrtifkd ropy thereof(Set. G EA PARKFEE Y N
3800,Lab C.) —
Policy x RECEIPT x
Co.�����mPPP"..), G BUILDING DIVISION FEES.
�CertNed copy b hereby with
city GREASE/U rDUSIRL W PLANCHECK FEE
Certified copy ts filed with the city Inspection dividon. ,rn ��
CERTIFICATE OF EXEMPTION FROM WORKERS' GR PAID a �L
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200PT. Date Recei 4# 6,O—in CD
(This section need not he completed if the permit is fm one hundred dollars
(f100)orfy the WATER HEATER W/VENT/ELECTR N
I llnut that o the person in of thewmkso as to bli tispermit c bored,
L shall not employ any person in any manner w as to berme subject to the WATER SYSI.EM/TREAUN'G
Worken'Compensstlon laws of UBfomts.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Da
4e Recei t#
Z O NOTICE TO APPLICANT:Ibafter nuking this Certificate of Exemption,you
should become subject to the Workera'CompensaHon provisions of the Labor TOTAL:
N Code,youmustfmthMthmmply Mthsuchprovbiovorthbpemtsha7lbe G. -E - y
W > deemed revoked.
o CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyalfirenHut there las mnstrudion lendingagemy forties perform, D ELECTRIC FEE
Z anceollhewor for whlcht b rmit blew �Ee��p97 CIv,C TO
U O lender's Name'[_' r.�io If/A /. ! %/ .y k _ PLUMBING FEE
LL V Lendeer's Ayddres. em�P bnand[ate ttheabove�tsforrtut'IonMECHANICAL PERMIT FEE MECHANICAL FEE
O W bmrned.Iagree to comply with all cityand muntyordinances and pate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby autherbe rcprxsentatives of this
1— N city to enter upon the above.mentioned property fm inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify and keep harmiem the City of Cupertino Date Recei t#
V agalnst Babilittes,judgment,City and expenses which may In anywayamue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
.against uiaL/ nr the gra tg oftM.pem,ic AIR HANDLING tIMT OVER 10.000CFM7 CONSTRUCTION TA
fi [i Pe a�9/ CONSTRUCTION TAX PAID:
Signature of AppBmmd., Data EXHAUST HOOD(W/DUCT)
PAID-
HAZARDOUS MATERIALS occupant atom
Will ia the defined
theC mbuil M.Mci pentode, hapten le herardous HEATING UNIT(TO 100,0000711) Date RecCi t#
material as defined by the Cupertino Munidpal Code,Chapter 9.12,and theLass alksk
Health and Safety Code Section 75532(a)7 HEATING ITMT(OVER 100,000 BTI!) TOTA
Ye g No 'Fx3�A
Will the appllcant future building occupant use equipment or devices' VENTILATION FAN(SINGLE RESID) ISSi4AACF J)AT`E
which emit Fennioua air contaminants as defined by the Bay Area Air RR'' F,iT�J-
MP
OR 10B000
. Thavetreadthehtaaadous aterials requirements under Cha pier 6.95 of BOILER-CCOOMP(OVER10D,000BNM {�� 19 1991
the Califmnla Health h Safety Code,Sections 25505,25533 and 25534. I NOV
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which mud be rest CI IT Vr cupt„I III,
priorlo Issuance of rtlricale of pan V
Owner or authorized agent fDatero ISSUED BY:
OFFICE COPY