2109 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buudin P.J.I Identification PIILMIT NO.
Building Address: 22109
'�/"I al 0/1
9
( 124- HrJ�T�2S ToN 1— cc> T(I.50 . GG I
Phone: p p
Avidy Hou CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.Na APPLICATION I PERMIT
BULLDINGELECTRICALPLI BINC MECHAMCAL CATEGORY CO,','rrr^�''L O
ATr-c�hitpe t/Engineer: LIc.No: V S
U>)VIL� G'21�'TlO QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: - BL� hl_�I PLUMB MELEE
PERMITISSUANCE - � � 'Ds—
affirm
CONTRACTOR'S DECLARATION
I hth bdion7O Hut lam Bcen3ofthe under
usimmalons nd Pmfes ptms9(mmmmc- APPI-IANCFSRFS7DENTIAL JOB DESCRll'DON
Inense i in fon 7000).!l effect.
n3ofthegusinesaand ProfessloneCode,and my �r� L
license tin full form and c.# PANELS �J
License Class Lk.p
Date Contractor —UP TO 200ANIN
ARCHITECTS DECLARATION 701-1000 AMPS
�
7p c recorFQ
I understand my plans shall be used as public OVER 1000 AMPS SQ.FT.FLOOR AREA $/ .Fr.
b u Licensed Professional SIGNS ELECTRICAL
6� OWNER-B OLDER DECLARATION
Z I,G�ji I hereby an that l am exempt fromthe Contractor's License Law Law for the SPECIALCItCUIT/MLSC
pp g full fBn
owing reason on.(Secti70315,Business and Professions Code:Any city or
FZF' countywhich requires a permit to mmm
trud,alter,improve,deolish,orrepair TEMP.METER ORPOLE INST.
anystrumons prlorto its Wuance,abo requirestheappllcant for such permit o
ES O t. file a signed statement that he t licensed pursuant to the provistom of the POWER DEVICES
W6 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.�Og sion3oftheeusinessmd Professioro CoclOorthat hebexempttherefromand SWIMMING IDOL ELECTRIC VA7,jjATION
' the bi ab for the alleged eaemptlon. Any vI.IkEon of Section 70315 by any eL G//
applicant for a permit subjects the applicant to a civil penalty of not morethan 1 OUTLETS-SWITCHES-FIXTURES ISQ / [�'
j8pave hundred dollars($M. `
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTR SQFE SIpRIES TI CON5MUCnON
p perry,or my employee with wages as their sole
romp.ruaHon,wllldothe work and theserocturetna intended or offered for
D sale(Sec. pply to alnowand property
wCode:The or Impmves Llmmelaw
r $� does not apply roan owner orthrou h who nem orlmprovnthereorymd OCCGROUP RES.UNITS
who
ovdoes
ments am
khimsen edm utghedaorA em ployees,providedthat ilding h
Improvement arenm Intended.missedforsale.IL mventrtdderwdingve TOTAL: l 6
improvementtsoldwlthln on.yearo(<ompledorythe owner-bu0derw111 have
T
of pmvlng that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE R,Opp ZONE APN
s owner of the Property, Se exclusively contracting with licensed PERMIT ISSUANCE 1V`I
Afl=
r to construct the project(Sec.70Kapp]Business and Professions Code: -4
Contractor's License law don nu apply to an.weer of property who ALTER-DRAIN&VENT-WATER(EA) �••I
Improves thermry and vehn contracts for such p,"with a 4�
�gLtfactor(-)licensed pureuant to the Contactor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
[_J 1 am exempt under Sm. B &P C for this reasons
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. -2,m SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT I
01 hereby affirm that I have a certificate of consent to self-Insure,or a I FIXTURES PER TRAP '1,00 SCHOOL TAX Y N
certificate of Workers Compevatloninsurance ora certified copythereof(Sec. RECEIVE#
3800,Lab C.) GAS EA-SYSTEM-1 WCAOTTLB1'S PARK FEE Y N_
Policy x Rp��.N
Cnm any CAS EA.SYSTEM-0VFRdLEA) BUILDING DIVISION FEES
[7CerUOed mpyis hereby th the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CenUed copy t filed with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID 6-act] (_11B776COMPENSATION INSURANCE �y L
(rhlssection need Adis becompleted ifthe permit tforone hundreddollars SEWER-SANITARY-STORM EA.700FT. Date Revel [# 7"l a`'
(8100)or Icss.)
I mrtlfythat in the perfonnanceofthe work forwhich this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person in any manner so as to become subject to the
Workers Compensation Lawsmf Callfomt.Date WATER SYSTEM/TREATING
OZ Applicant
PAID
ZO NOTICE TO APPLICANT,ILaNer making thio CenRicate of acorp,,no you NEWRESIDENTIALPLMB. SQFr. Date Recei [#
F .hold become subject loth.Worken'Campematlon pmvti.na.fish.Labor TOTAL:
WW Code,you must forthwith comply with such provikoru or this permit shall be
> deemed cooked. BUILDIN I
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affirm that there t a construction lending agency forthe perform- TOTAL: ELECTRIC FEE
ance of the work for which this permit Is Issued(Sec.3097,Civ.C.) I
LL2 Lender'shame PLUMBING FEE Oa
LL ~ Lcnaer:Aaaren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtlfythatI have read thbapplicationand statethat the above Info Los 1 urorn'ct.lagree to comply with all city and muntyordlnanmand state laws PERMIT ISSUANCE I�m FEES PAID:
} N relating to building construction,and hereby authorlu representatives of this
H Z city to enter upon the above-mentioned property for inspection purposes, t ALTERORADDTOMECH.
(We)agree to save;indemnify an d keep harmless the City of Cupertlno �` Date Receipt#
Against Babi0les,judgment,mks and expenses which may in anywayamue AIR HANDLING UNIT ITO 10,000 CFM)
against aid City in mnatquence of the granting of this permit. SUBTOTAL'•
AIR HANDLING UNIT(OVER la"CFM) CONSTRUCTION TAX
'ignature of Applicant/Contractor Data EXHAUSTHOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Mum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date —` Recei t#occupant
IIealth❑Ynand Safety Code, Noon 75537(a)7 HEATING UNIT(OVER 1 W,000 BTU) TOTAL•
Wlllthezpplicant or iuturebullding ocmpam use equipment ordevicesFBOILr—R
M
ISSUANCE G51'FE`��"
which emit hazmdous air contaminants as defined by the Bay Arca Ale
. Quality Management DislHct7 DIP OR )
Yes FFu�No
have read the hazam`Tous materials requirements under Chapter6.95 oftheCalif.mtHealth&SafetyCodeSections7550.5,75533and 75536.Iunderstand that lithe building does nitmrrently hay.atenant,that it ismySQFT. CJI O�CUpBI�lf10
responsibility to notify the occupant of the requiroments which mustbemet �y1 V IJOprior to Issuance mfa Certificate ofOccupancy,Owner or author.agent Date
TOTAL: C SSUED
OFFICE COPY