22262 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMIT NO.
Building Ad� \-1 V 2^
6 2
22262
w arrc: one: G G G VM G
CITY OF CUPERTINO,BUILDING DIVISION
A A A
Con=Name: Lt.N.: APPLICATION / PERMIT
\ Atchimet/Englnee Lie No: BUILD(NGELECTRICA4Ir_UMBING-MECHANICAL CATEGORY CONTRT,�n
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE 2,0 DBLOC ❑
LICENSED CONTRACTOR'S DECLARATION 14
. Thereby affirm ihatlam licensed undn prwislnne ofChapter9(cammeno- APPUANCESRESIDENTIAL JOB DFSCI(llTION
Ingweh in full
force. Dlvfect. oftheBminessandPm/essionsCodG and my � ` _
limn.Isins farce and effect. PANES CV
Date
)a Jl
Llrenx Chea LILY
Date Condor
ARCHITECTS DECLARATION AI-IOW AMPS
wNOw ZO I understand my phm shall be used as public record.. OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.F7.
q�q U Fj Llcenxd professional L C
`6w OWNER-BUILDER DECLARATION s
Ihereby affirm ihat lam exempt from the Contractor's Limn.Law(a the SkVL CTAT/ I too �}l 2,Si�
O G following rectors.(looters 7011.5,Business and Prolamines Code:Any city or l L.1J
F
hichm 1 permit to construct, pro p u,Ts u�
county which qu mope 4alleLim improve,demnlmh,or re air IN/
$ < any tatemethat heislicensed p oat. to
ime suchpermlte p(y '0 -
:_O O Roe a dgnr's statement
cens eLa that he(Chapter 9lic(cod pursuant it the pro 7DOO) of the
san3 rte�lil,inem.�a or ha8he is e.�emmnt (m(mnd
SWIMMING POOL ELECTRIC vi
VALUATION
y.' the bash for the alleged exemption. Any violation of Sectiont 7m15 by any '�qq
pi ZOUTLETSSW7CHFXRE
applicant fora permit sublnstheaPPlicant to a civil penalty tyofnot more than
LOD
live
hundred dollars%500).p�.
NEW RESIDENTIAL ELECTR SQ.FT.
I,asowner ll theework,aor my employes with wage. rt heirrole STORIES TYPE CONSTRUCTION
wmpematlon,wnl do the work and the mm�vre m not Intended or offered(or
��❑ vie(Sec.70N,Bualnrss and Ilofessbns Code:TM Contractota Llmnse Law
$$ whorl applytorkhi elmthm hmso nemploym%w idMeon,and atwch OCC.GROUI' RES UNITS
whodoemoasa notinte
oough M.owne.If,ho eprovidedthing or
Improvement issold ithindedoroffend plefloc.Itbowevepiheerwill haw TOTAL: � UO
Improvement m sold within one year of compinlogthe owner-bullderwlll have
t"Men proving that M dm not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLODD ZDNE APN
Ll L ae owner of the pmpeny,am exclusively mntraning with"'e— ERMIT ISSUANCE
contractors to construct the project(Sec.7016,Business and Pmfealov Code:
The Contractors License Law does nn apply to an owner of property who iFR-DRAIN&VENT-WATER(EA)
Wilde or improves Nemo^,and who contracts for such p\ojeds with a
¢I otr(s)licensed pursuant to the Coetranoes License Law. FEE SUMMARY
151 am exempt under Se B& P C for this mason BA4 FLOW PROTECT.DEVICE
QUTq1 Qu FEES
Owner 'Date DRAT FlDORROOEARFk D. SANITARY Y_ N_
RECFAT Y
., WORKMAN COMPENSATION DECLARATION SCI100L TAX Y_
❑I hereby affirm that I have a mrtlRam of con..m m w
xl(-Inm,w a TRAP N_
RECEIPT N
38(0,his C.) S F.A.
ceniflateWorYen'Compensailonlvurancrma<ertlfled wpythemo((Sec. GAA. -1 INC OUTLETS PARR FEE Y N
PaltryN GAS EA.SY 4(EA) Lill
Of VI
C°_��___^_______'pppppp+ato�aany BUILDING DI VISION Fr,ES
Certified copy m herebytume city CRFASE/INDU WAsEWTFRCEPTOR PLANCHEGI(FEE
/Jr@�(LCenJM ropy ii,filed with that city W pectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID 6--t"kftl C7^}�
COMPENSATION INSURANCE �p �.ARY M E.A.�T Date RCCLI [N Oct\ G
Hhbxctlon need nu
COMPENSATION,
mTenons hundred dollen
a1W)alem.) wA HEATER w/vENr EcrR ENERGYFEE' Y N
I artifythat In the performance of the work forwMch this permit is lowed, —
I shall not employ any person in any manner o m to became wbjen to the ATER SYSTEM/TREATING
workers Comprnvtlon Laws of California.O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei tN
Z O NOTICE TO APPLICANT:](,after making this Certlfiate o(Exemptlon,you
Fshould become subject to the Workera*Compensation provisions of the Labor TOTAL:
N Code,You at forthwith comply with such provisions mthm permit shall be 0
BUILDING
> deemed revoked. t 5
QW. 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyaffirmthat then m a construction lending agency forthe perform T TAL: ELECTRIC FEE ��vU
ance o(the work for which this permit is Issued(Sec.3097,C1v.C.) PLUMBING FEE
V O Lender's Na
LL F lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtve i/ythat l hamad thhapplicatum and aamthat theabove Information
mcorrat.l agreetocomplywlth.Udty.M amaryordmanm and state laws PERMIT ISSUANCE ''2- FEES PAID.
l >_ N rola ingtobulldingcomteaction,and herebyauthorlu reprexntativesofthit GJ
Z city to enter upon the above-mentioned propery(or Inspection purposes ALTERORADDTOMECH. (-dD veDate ReCEI tN
_ (We)agree to sa ,indemNfy an d keep harmless the City of Cupertino P
agoest lhbllitie.,jadgmenm,wsmand expenx.which mayinanywayacame AIR HANDLING UNIT(170 10,0DO CFM) SUBTOTAL: -
ago aid Cit In rens era the granting of thio permit.
1���/ - 710 1 AR ANDLNGJNTI' OVERIO,OOCFM) CONSTRUCTION TAX
Sig�f/Cp B rat/Ccntranur Dam EXHAUST HOOD(W/DUCD - CONSTRUCTION TAX PAID:
�� A]ARDOUS MATERIALS DISCLOSURE s(
Will the applicant or future building onupant slum urhandie haardous HF.ITINGUNIT(I01(0WB'M
, O -O('/ Date RLYei tit
materhl as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the �f?-�
I1.1th and Safety Cade Section 75532(a)? HEATING UNIT(OVER 100,000 BHA TOTAL: 36 a-
❑ Yes M No
Willthe applicant orfuturebuildingompantuxequipment ordevices VENTILATION FAN(SINGLE RESID) $�SUA EDATE
which emit hazardou.air contaminants ae defined by the Bay Area At,
Quality Management District? BORER-COMP OHP OR 100,0(0 BTU)
r I Ya f—I No
have read the hararmateriab requirements under Chapter 6.95 of BOILER-COMP(OVER IW,OW BTU) JULQ
the Glifomh Health&S�fdy Codeect
,Sions75505,75533 and 7S534. I M (i1
understand that if the building data not currently have a tenant that it Is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to really the occupant of the rqulrements which at be met ofprior to issuance ofd CertificateofOmpanq. Ck I
*05 ift-
Owner or authorized agent Date TOTALOD In.S•UEDBY: `y' -tat(, ku
: �}
OFFICE COPY