22641 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
co
Building Pm ca Identification PERMITNO.
tlullding Addrer:
22641
m s ante. n A
CITY OF CUPERTINO-BUILDING DIVISION
tractor's ante: LIc,Nm APPLICATION /PERMIT ,
BUfLDINGELECTRICAI.PLUMBINGMECHANICAL CATEGORY CONIR .X/` /t T
Arch set/Engineer. Lic N.
V� cUV
QTY ELECTRICPERM/T FEE BUILDING PERMIT INFO
Address: I'FTttATI55IlANCE � I� X ❑
LICENSED CONTRACTOR'S DECLARATION �Q�
I hereby ection mthat Diviol am ..Riseunder Busi bldPmfeWonr9de,and c APPLIANCESRESIDEM'fAL JOB DESCRIP170N
It-1 t.wf000)of Divldm3ofthe Buelnmand ProferlonsCode,and my
L 'e, In(salt and d(ect. PANELS
License r Lk.N
Date ContractorUPT02DO AMEM
ARCHITECTS DECLARATI 201-IfDO AMPS - ,
ce0 Z I understand my plan sisal be used r public s OVER 1000 AMPS SQ.FI.FLOOR AREA $/9Q.FC.
aOCO
Licensed Pnefmional SIGNSELECTRICAL f too 4 ax3$
6 Fkgo OWNER-BUILDER DECLARATION `�,�J l
In SPECIALCItCU1T/MISC �y
09- owingrIhembyaffimthatlam31.5,Business fro and ntracturesCode: aw roethe �j —1
Foo countyw rceson.uncapction rmittoommuct and Professions Code:Mycity it
Z"� ]EMP.METER OR POLE INST.
� county which tcqulrnapertNtromrutmct,alter,Impmve,dennWh,orrepalr,
q any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
[5 O file a signed statement that he is licensed pursuant to the provisions of the
PW1 Contractors License Law(Chapter 9(mmmenirg with Section 7D0()of Diel. SWIhpgNG POOL ELECTRIC VALUATION�s eon3ofthe Budnessand Profmlom Code)orthathebemmptthemfmmand
6 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWIT'CHESFLXT URES / � a o
applicant lore permit subjects the apphcanttoa civil penalty of not more than
flv�undred dollen($SOO). NEWRESIDENTIALELECTR SQ.FT. E$ TTyyPP�[ O STRl1CT10N
�n is a owner of the property,or h. employees with wages r thele sole s /E C 1
crnpsnrtion,B.doethework.and thestmau71 is henot Cotractodor offeredLaw H C
O don Sec.apply
to anow arWProfmlov who
Wild,C improvens Lt.hervee Law
$$ dao net
suchoan owner of property whebu mpoymprovothereoRand
who does tints am khimaen ed roughedor employees,how,providedthatsuch
Improvementsarenot intended earofco forole.1[however, gder l lI have T'Tmef
Improvement bwld within he
rust completromprove for
purpose
of sale.).
have
llg;-kur as o neerprovingof the pr eeW na excluild usively
improve ting with
livens. QTY. PLUMBING PERMIT FEE
Ltr[as mucor tr the property,em exclusively Business
and
with ns Coed PERMIT ISSUANCE
TheconCo ors to consimnsect Law ject does ec.nor appy to nt owner
of pro ons Code: % W
The Contractor's License Law don cart apply ct an owner a Property who
o"p.tbuilds.or Improve thereon,and who contracts for such p[ojecb with a ALTER-DRAIN VEM-WATER(EeU
cp_jLa exempt pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec B &P C for this reason BACK FLAW PROTECT.DEVICEOUTSIDFFFrS
DRNNS FLOOR ROOP,AREA,COND. SANITARY Y N
Owner Date RECEIPT M
WOR KMAN COMPENSATION DECLARATION FD(Tl1RES PER TRAP SCHOOLTAX Y_ N
C31hereby affirm that I have a certificate
of consent to self-Insure,or a RECEIPT N
certificate ofWorkera'Compensation lveueence or a certified copy thereof(Sec. GAS EA.SYSTEM-1 A'CAOUTLEfS �� PARK FEE - Y_ N_
3800,t bC.) RECEIPT'N
PolicyN GAS EA.SYS W' OVER 4(EA) BUIL DING DIVISION FEES
COm ny
Certified copy b herebyfurnished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PI"ANCHECICFEE
Certified copy b tiled with the city IvpecHan division. Y� a.
CERTIFICATE OF MEMPTION FROM WORKERS' GREASETRAP PAID���' (•� a--/'^�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20017 Date Recef Iq :Jo• /
(This section need net be completed If the permit Is forone hundred dollars
($10(i)or leo') WATER HEATER W/VENT/EL[CTR ENERGY FEE Y_ N_
I certifythet In the performanceof the work for which this permit Is boated,
I shall na employ y eraon U t) mance n� marc d to the WA•I.PR SYS)FM/.IREA•DNG - PAID
Workers'C v we to L(i
O Z Applicant NEW RESIDENTIALPLMB._SQbT. Date Rewe tN
Z hOlICE TO PLICANT:It,after raking lis erti Vole of Faemptbn,you
should becomesubject ro the Workers'Cem allot provisions of the Labor . TOTAL:
N Code,you must forthwith comply with such provisions orthb permit shall be BUILDING FEE
W j deemM revoked.
CONSTRUCEION,LENDING AGENCY SEISMIC FEE
IL Iherebya(flrmthat there b a comtructlon lending agency for the perform- TOT ELECTRIC FEE
D Z ance of the workfor which this permit is Issued(Sec.3097,Civ.C.) 1.
02 Lenders Name PLUMBING FEE
LL F Lenders Add. QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
N O I cerdfythat I have read thbapplloilun and statethatthe above Information
W Is correct.I agree to comply with all city and county ordinance and nate laws PERMITISSUANCE FEES PAID:
CL
} N relating to building construction,and hereby authorize representatives of this - _.
f. Z city to enter upon the above-mentioned property fee bapectiun purposes. ALTEROR ADD TO MECH. Date ROceiptlf
(We)agree to save,Indemnify an d keep harmlm the City of Cu pert Ino
V egaNat it blI ,pdgmenb,cortaandexpenseswhichmayinanywayacaue AIR HANDLING(INR ITO 10,000 CFM) SUBTOTAL:
.gal d It consequence of ant this permit.
AIR HANDLING UNIT(OVER 10,000 CTTT) CONSTRUCTION TAX
S .turemAppOcant/Contndar Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARDOUSMAT LSDISCL SURE
Will the applicant or future buildingo ntatore rhandlehazardom HEATING UNIT CFO 100,OW BTU) Date ReceI tN
material as defined by the Cupertino MuNdpal GC apt.r9.IZa.dthe
Health and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,00(l BTI) TOTAL:
qYes No
llltheapplimntor mmbruildingampantusecquipmentordevico VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
whichemit hazardous air contaminantsas defined bythe Bay Area Air PAID Qu Illy Management District? P
7 BOILER-COMPDHP OR100,0(DBTU) AID
QYo F1 No
Rha .read the h.Vus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI) ee}
the California Health&Safety Code,Sed love 25505,25533 and 25536.I
c� unit ersta nd that if the W lld Ing does not currently have a tenant,that It b my NEW RESIDENTTAL MECH. SQ.FT.
rrpomibWty to ofa the part oft he rnprirementswhich must be met
pdortotame bady to nosy the to o(toftheOcou pa nay.
Owner or authorized agent DateTOTAL: ISSUED g . C
OFFICE COPY '