22575 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address: 22575
. �ti - �.�
nos ams. - one: A A
C� CITY OF CUPERTINO-BUILDING DIVISION /
c°ntr n°pq �� LIc.No: APPLICATION / PERMIT —
Architect/Engineer: Lie No: 1
W BUILDING ELECTRICALPLUMBINO-MECHANICAL CARY CONTROL a
QTY ELECTRICPERMIT F BUILDING PERMIT INFO
LLLcl PLUME
Address:
PERAIIiI55UANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
ion700that lamlkrnsedh.under Businseaiovof Chapter
ssions9(mmmmc APPLIANCFSRESIDENfIAL JOBD RIPTION
Ing cense 15In full 000)of Division ofthe Buslnneand ProtesslonaCnde,and my
license la In s force and died. PANELS
LicenseCWss
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS -
rc0 Z I understand my plans shag be used ss public records. OVER 1000 AMPS i 5/SQ.Ff.
CO
Licensed Professional SIGNS ELECTRICAL •�
a61 OWNER-BUILDER DECLARATIOiq _
s- .4 IherebyalRrm that[am exempt fromthe Contractors License Law for the SPECIAL CB{CUIT/MISC �,.-.
pp following reason.(Section 7031.5,Business and Professions Code:Any city or
F?.i.� rountywhichrequiroapev ttommtmct,alter,lmprove,de=lbh,orrepair TEMP.M=OR POLE INST.
'� '� anystmcture priorto its ixtuance,also requlresthe applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the ]'OWER DEVICES
q Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
slon 3 ofthe Business and ProfesalonsCode)orthat he 6 exempt theretromand VALUA pp//yy11
y the basis for the alleged exemption. Any violation of Section 7031.5 by any OI71LE7SSWITCHESFIXTlJRFS C V s �S/
pas applian ora permltsubjects the applicant to a civil pevltyofnd more Hun
c & fix Bred dolbts(SSM. NEW RESIDENTIAL ELECTR
,as owner of the property,or my employees with wages as their sole `SQ'pT' STORIES TYPE CONSTRUCTION
C mmpensation,wfildothework,andthestrudurebnot intended or offered for
❑ sole(Sec.761y Business and Professions Code:The Contractors License Law
s� does not apply to an owner of property who Wilds or improves thereon,and OCG GROUIs RES.UNrFS
C• whodoxasuchworkMmselforthr°ugh hlaownemployees,provided that such
improvements are not Intended oroffered formic.If,however,thebuilding or TOTAL:
Improvement iesold MthinoneyearofcompleiogtMo ner-builderwill have
the burdenof previngthat he did neebtild or improve forpurposeo(sale.). QTY, PLUMBING PERMIT FEE FfAODZANE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constmet the project(Sec.7016,Business and Professions Code:
The Cont radors License Law does net apply to an owner a property who ALTER-DRAIN&VEN7-WATER(Ela)
Wad.or Improves thereon, and who contracts for such p(o)ects with a
mj[ador(a)licensed pursuant to the Contractor's Lrenis Law. FEE SUMMARY
LjI am exempt u &�P SC, lot th/e ree/on BAIX FLOW PROTECT.DEVICE
pwr�ys `l/-: Datayy/`//� DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
IOF� 7— RECEIPT
WORKMANCOMPFNSATIO LCLA p0(TTIRES I'FR TRAP —SCHOOL TAI( Y N
❑i ate of sheen toss i n a of conunt to self-insure,ora RECEIPTN
certificate of Worken'Compensatlon lruurana oracertlfkd mpythereof(Sec. GAS-EA.SYSTEM-1 INCA OUTLETS
Polis38M,lab CJ PARR FEE Y N
Policy tl RECEIPT p
Com any GAS EA.SY51'FM-0VERd(EA) BUILDING DIVISION FEES
MCedlfied copy is herebytumecityialud. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHE•CK FEE
copy V filed with the city inspection division.
CERTIFICATE OF PXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlssection need not becompleted lithe permit isforarehundrei dollars SEWER-SANITARY-'STORM EA.200FT. Date Recet t#
(E100)orfy that
WATER HEATFRW/VENT/EI.ECTR ENERGY FEE Y N
I certify that o the performance of the work for which this permit is Ito th, —
I shall not employ any person in any manner se u to become subject m the WATER SYSTEM/TREATING
W°rlicis ComLaws we of California. Date PAID
O Z ApplicantZ o tiOTICETO APPLICANT.It,after M making this Ceniflateo(Exemption,you NEW RESIDENTIAL]'LMB. SQFT. Date Rceei t#
should bemire subject to the Workers Compensation provisions ofthe Labor TOTAL:
CC
Code,you must forthwith comply with such provisions or this permit shall be
W > deened revoked. BUILDING E k
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE a
= Z Ihereby afRrrothat there is a mnstmctlon lendingagencyforthe perform TOTAL:
ELECTRIC FEE
!) anmofthework furwhichthb permit is issued CSec 3097,Civ.CJ
V Lenders Name PLUMBING FEE
ly F dcrbAddreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythat l have read this appliationand satethat theaboveinformation
1 0correct.l agreeto comply with all city and county ordinances and sate lawn PERMIT ISSUANCE FEES PAID:
N relating to building construction,and herebyauthorirerepresentativesofthis
(— Z atytoenteruponthe above-mentioned property for inspection purposes. ALTERORAODTOMECH.
— (we)agree to save,lodes N and keep harmless the City of Cupertino Date Receipt#
agalint Ibbillties,pd e ssandex se maylnanywayaccnie AIR HANDLING UNIT(TO 10,030CFM) SUBTOTAL:
X61 s 1 it of a Ft l�d this permit.
n 4"4/ or/,6� ( AIR HANDLING UNIT(OVER I0,M0CFhU CONSTRUCTION TAX
re al Applicant ontrador 9 O�/Date IXHAUSTHOOD(W/DUCT) CONSTRUCTIONTAXPAID:
HAZARDOUS MATERIALS 131SCWSURE
Will theappliamor tuturc Wlidingompant store or handle havrdous HEATINGUMT(IO100,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
He❑alt hand Safety Code,Section 25532(a)7 HEATING UNIT(OVER 1 Wp00 BTU) TOT
A
Will the applicant orfuture building occupant useequlpmem ordevices VENTILATION PAN(SINGLE REBID) ]SSI ATE
which emit havml
rdous ab mntanants as defined by the Bay Area Air
Quality Mawgement District? BOILER-CAMP OFE'DR 100,000 BTU)
4Ys gNo p
nave read the hazar ey Codri ls Sedionirement 25533 and 2S5r6.95 of BOILER-COMP(OVER IW,ON BN)
the Calilornia Health&Safety Code,Sections 25505,25533 and 7x534.1
understand that lithe building does not currently have a tenant,that it B my NEW RESIDENTIAL MECH. SQJ7, �
responsibility to notify the occupant of the requirerrents which most be,met
prior to Issuance of a Certificate of Ocmpanry.
Owner or authonud agent Date ISSUED BY:
TOTAL:
OFFICE COPY