22478 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building �6T6�''C�'S 22478
Address: �c
oera ams: one: A
CITY OF CUPERTINO-BUILDING DIVISION _,Z '
Co a o Mane: Lie.Nox APPLICATION /PERMIT
n:6 q43303 BU]LDINGELFCTRICAL-MU HING-MECHANICAL CATEGORY CONTROL#
Architect/Engines Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERKTISSUANCE QJ f�71 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LG
I�Yn full thaatnldcm3r A `fdl
C9( m
APPLIANCES-RESIDENTIAL
IngwithSction7O00)o(DiWW=3oftheBusnemandPm(nsionsCoe,andmy PANELS JOB DCRB'1'ION
"ren
Date
ryC
ARCHITECTS DECLARATION 201-10(11,I0a) PSM
07 Iundentand my pore shag's used as public OVERt000 AMPS `QIFq f/SQ.FT.
O L ` t
Licensed Professional SIGNS ELECTRICAL
�<} OWNER-BUILDER DECLARATION SPECIpLCIRCUIT/MIRC nM vi P
7F, a Ihembyaffinnthatlam exempt(romthe Contractors License Law(oaths V
p following reason.(Rection 70315,Business and Professions Code:Any city or ®.
Z I- TEMP.METER OR POLE INST.
5 any structure
requlresa permkroalsore�Atmals theaprovgdemouah,ormpir mitto
.e any atmdureprior
enits that he
pursuant
to the rovisihpeof to OWER DEVICES UAIE 49'
file a signed License
that he t r9lic(commencing
pursuant it the provbl0) of the
Ou, Contractors License law(Chapter9(mm)orthagwRhSemptthe00)ofDlvi-
3 SWIMMING POOL ELECTRIC
the Wafthe the usiness
Profession, Any solation is exempt therefrom and �• 11L�II VALUATION
the
'j the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES FIXTURES �s W l 2�[) O
appiksMfor.permit subjects the applicant to a civil penalty of nor morethan \ J—
five hundred dollars(SM. NEW RE4D-NHAL ELECTR SQ.FT. STOWIS TYPECONSTRUCTION'
O ❑i,as owner of the property,or my employees with wages as their sok
C compensatlon,will dothewwkand lheatroaWrebnM intended or offered for
$ ❑ sale(Sec 70K Business and Prefosslow Code:The Contractors License Law
does not apply to an owner of property who Wilda or improvesthemes,and
G who doessuch work hlmciforthrough his own employees,provided that such OCCGROIIi' RFS.UNITS
impevemenioarenotintendedoroffered fwsals.ILhowevegthebulldingor TOTAL: CJ
Improvement bsold withinoneyearofcompletlon,the owner-budderwtll have
to mien of proving that hedid notbuild orimprove forpurpoxofsals.). QTY, PLUMBING PERMIT FEEFTgoDZONE APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to com ud the proper(Sec.7(M4,Business and Pmfessiom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
W Ilia or improvm thereon, and who contracts for such plojeae with a
➢I(actor(s)lirenwd pursuant to the Contractor's License Law. gAGK PLOW PROTECT.DEVICE FEE SUMMARY
Cq
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FDUURES PER TRAP SCHOOLTAX Y N
hereby affirm that I have o tt asurane of consent to opythvre ora RECEIPT#
certificate of WorkersCompensatloninsuranre ora ttrtl(kd copythereof(Sec. GAS EA.SYSTEM-1 INC.60UILE15 PARKFEE Y N
3800,Lab )
Poilry GAS-EA.SYSTEM-OVER 4(EA) RECEIPT N
Com any _ mss. BUILDING DIVISION FEES
CertlBed ropyb hereby(urnbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK
CertlRed ropy b filed with the city Inspectlondivision.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID G �)
COMPENSATION INSURANCE SEWER-SANUARY STORM EA 200FI' Dat RCCCI t#
(ThisseNon need not be completed if the permit b forone hundred dollare
(81I mmfess3 of WATER HEATER W/VENT/ELECTR ENERGYFE Y N
I rent that o the performanceny co work so as to which this eemdt is c ito the —
I shall not employ any person in any manner at ns to become subject to the WATER SYSTEM/TREATING
Worken'Compematlon Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB.
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you __SQ.FT, Dal R Cel t#
should become~ subject to the Workera'Compematlon Provisions of the Labor T AL:N Code,you must forthwith comply with such provisions or this permit shall be BUILDIN 'E
W > deemed ked.
revo
CL f] CONSTRUCTION LENDING AGENCY SEISMIC PE p
I humbyafilm that there b a consform construction lending agency for the per
:5Z ance of the work for which this permit b Issued(Sce.3097,Civ,C,) TOTAL: ELECTRIC E
U O Lender's Name QTY. MECHANICAL PERMIT FEE '
U. I
PLUMBING E
h- .enders Address MECHANI - FEE
O W Iranifythailluvemadthbapplkatbnand Aatethaltheaboveinformatim -
a Is correct.lagree to comply with city countyomdlnanmsand state lawn I'ERMI'I LSNANCE FEES PAID:
} W relating tobulldingmmtructlon,and herebyauthorterepreaentativnofthis
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDIO MECH. ,
— (We)agree to save,indemnify and keep harmless the City of Cupertino Date Ree pt#
agaimtBabiBties,judgmenb,amtsandexpenxawhtchmaylnanywayac a AIR HANDLING UNIT(TO 10.000CEM) UBTO AL:
agamgsaid C1tyfmmnaequenceofthe graining oft permnit
('/n..� 1� �� (qT1= AIR HANDLING UNIT(OVER 10,"CEM) CONSTRUCTIO TAX
Sig®mreo Appllont/Contractor \ is 1�I� IXHAIISTHOOD(W/DUCT) CONSTRUCTdON TAX PAID:
HAZARDOUSMATERIALSDISCLOSUR �C
Will the applicant orfuture building occupant store v
or handle hardous HEATING UNIT(10100,0WRIU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date CC t#
II.Ith and Safety Codr,$ection 25532(a)? HEATING UNIT(OVER 100,000 BTU)
F1 Yes T
` u No T '
Will the applicant m tum building occupant use equipmsnt or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management m(ct? BDILER-COMP OHP OR 100,000 BTU)
4YesNo
haveread the haear ousmateriakrequirements underChapter6.95of BOILER-COMP(OVER 100,000 BTU) Pl�yy
the Celifo rdi health k Safety Code,Stolons 25505,25533 and 255M. I {-ry+gp�
understand that if the building does not currently have:tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. r
mor to Issuance
ce ofa eheompantofthercquircments which must be met
prior to issuance of notify the occupant
of the req OSR<G tl
kmr
ttls 'Y-�'d"LeaF �1c
O2t9
wnero alai agent s J) ISSUED B7 f O
TOTAL
OFFICE COPY