22080 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
Building Project Identification PERMIT NO. -/�/ R
Bu ltd Ing Address: �/_ 22080
O V O
ger a Name: uxre APPLICA IION rAL DATE
2 - 4j CITYOFCUPERTINO-BUILDING DIVISION
C anoe Lie.No- APPLICATION /PERMIT
2r' O O BUfLDINC-ELECTR)CALPLUMBINGMECH MCAL CATEGORY CO,vy7R
A ten/Engineer. rr����,,� LI 41 (O
Z-. cY�-C7U RI BUILDING PERMIT INFO
I a 0 �t ELECTRIC PERMIT ^FEE
Address: PETLWTISSUANCE I /y(�O
LICENSED CONTR under rDECLARATION LSJ
T hereby ion70 that lamsiolicensed 3 oftheerpnrvlabnsofChicutsGde,and(ournmene-
my APPLIANCFSRESIDENTWL ]OB DESCRB'I'ION
lag with Senbn7000)ot DTvidon3o(the Buslneuand ProfeulonC�e,andm a.�_� �` ,
license PANELS
Limn -1 a Lic p
Dat Contre���-��
RCHITECPS DECLARATION 201-1000 A.MP5
a0 O I understand my Pict shag be used as public mond, OVER 1 W0 AMPS SQ.Ff.FLOOR AREA E/SQ.FT.
Fi Z�j Limned Profeuloml SIGNS ELECTRICAL
<<�6� OWNER-BUILDER DECLARATION SPECIALCIl2CUIT/MLSC Tl
7F. a Thereby affirm that?am exemptfrom the Contractor's License Law for the
O F. following reason.(Fenlon 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
K� county which requlresa pemdttocootom
ct,alter,improve,demolish,orrepair
q a anystromm,pciortoits Issuance,also requmeathe applicant forsuch permit to
lite a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
�Ou, Contractor's License Law(Chapter9(mmmencing with Section 7000)of Divi-pyyMNC POOL ELECTRIC
Oa sion3ofthe Businessand Pro(esslonCode)orthatheLexempttherc(romand - VALUATION
•..11 the balls for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit the applicant to a civil cal ofnn more than OUTLETSSWITCHESFIKTUREF (�
PP Pe^rd I� PP penalty I 1 J 531—c"
nr`. m /iFj1, a owner I the pr). NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees isa with wages r there sole c�23'T STORIES TYPE CONSTRUCTION
C7Q, coo(Sce.7DKfl,11dothard Pronealons unurehr nd C.. om?nded or offered for
j 0 doe rest apply
to an,owner
f poops oru Code:Tds or ice rown themes law
(j$ docs not apply to an owner of property who Wilda or Improves Thereon,and OCC.GROUP RFS.UNITS
CC.• whodoeeauchwork himseUorthrwgh hisownemployees,provided that such
Improvements arc not intended or offered for sale.If,however,the building or TOTAL: CD
i pmvement baold within one yearofcompinion,the owner-WBderwill have
the burden of proving that he did not build or improve for pu rpos,of ask.). QTY, PLUMBING PERMIT FEEp1ADDZONE ApN
El L as owner of the property,am exclusively contracting with licensed PFRMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contnciars License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
or Improves thereon,and who contracts for such plojecta with a
,,tfllLL[[0 a)BcansM pursuant to the Contractor's License Law. FEE SUMMARY
u
LJ I am exemptnder Sec. B& P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• WORKMAN COMPENSATION DECLARATION RECEB'(R
❑ rm I hereby affithat I have a certificate of consent to aelf-insure,ora FIXTURES PER TRAP 5Cfi0OL TAK Y N_
mdificate of Workeri Compenation imumnm or a mrtifbd copy thereof(Sec. RECEIPT p
3800,lab C.) GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y_ N
PoliComryan RECE]PIp
y BUILIJINC DI V ISION FEliS
Certified ropy is hereby furnished. jMwe,
❑CMificd copy ls filed with the city Inspection division. PLANCHECK FEE
CERTIFICATE OF E)(EMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE LL
(This section need not be compincd tithe perMt ls(or one hundred dollars Date Re i f 'aO'S
(51I es"lcuJ WATERHEATERW/VENT/F3,� EN' EE Y
II.hall oly th�atttb the ypedormanca of the d�k for thiels ehls peanatls t.the
Workersafm yi6ryLue ( an e(er j^be —1/gmthe WATIERS,STEM/T,RFA,DNC
z Z Applicant
Ci Gia- I V/ p
Z O NOTICE? MPLICAN'T:If,..ar ma am Cert caso ifFt emptlon,you NEWRE9IDFNTIALP(MB. SO PT ate RC I t#
F - shouldbecomesubjeettotheWoricaraC peraation prov6bruof the Labor
WW Code you muat forthwith comply with such provislow orthb permit shall be TOTAL:
> seemed revoked. BUI DING FE _
0.
0 ffiructCONSTRUCTION LENDING AGAGENCY 2T ISEISMIC FEE a. O
Z
I hereby arm that there is a constion lendingagenry(or the perform- l�.rsc�.(theworkforwhichthb Nrmitblssued(Seo3M.CIv.C,) TOTAL: ELECTRIC FEE
U Lo ake.N me PLUMBING FEE
LL Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1ourtl(ythat l have read thbapplicatienand satethat theabovein(omutlon �3,�
C lsromat lagree to comply with allcityand countyordinances and state laws PERMIT Lsw FEES PAID:
r N relating to building contmnion,and hereby authorize representatives of this '
Z City to enter upon the abovo-meatloned Property for Ice Non purpoun. ALTERORADDTOMFCH.
V — (We)agree to save,indemnify an d keep harm)e i of Cupertino Date eceipt#
again lea,' grrenls,cone end ea1 anywayaccrue AIR HANDLING UNIT 10,WOCFM)
I at $U OTAL:
a sal ence o( h a ' soft colt.
AIR HANDLING UNIT(OVER 10,"CFM) CON NT X
Signature of Appheare"rimmeor Date IXHAl15T HOOD(W/DIICTJ CONSTRUCTION T X PAID:
HAZA R DOLS MATERI SDI SCLOS URE
Will the applicant or future bu ilding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the _ Date Rei f#
Iles❑
Yea Safety CodL§p0ihnrNoon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) C a AU
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) �I st) _ CE DA
which emit hav mco
mous atr nte minanb as dented by the Bay Area Air 'yi�
Quality Management ? BOILER-COMP OHPOR 100,000 BTU)
IPIfJo MAY Y
'have read the hazzrTicaul materials requirements under Chapter 6.95 of BOILER-CONP(OVER 1W,000BN) ST 1 dhryl�
theCallfornb Health&Safety CMa,Smt1on25505,25S73and 25534.1 -
undentandlhati(the building does not Cur tlyhav anythatltismy NEW RESIDENTIAL MECH. SQ.Ff. -lL lel U/IIN�.Ir.
res Ili if the occupant of quire rata at
be met +��( I�faRaVN
or to' n IOcate of cry.
- Owner or authonzed agent p���+ .�y,� - ,r. J
TOTAL: ISSUED
OFFICE COPY