22114 (2) � „ _, __ . - n_ _
APPLICANT TO FILL_ IN INFORMATION WITHIN rIE^ '_'NFS — USE RiA'_'_
Building I'mject Identification ---- PERMIT NO.
Building Address.
22114
ne: A
- DnriJ 0-r-,a�TF5(D
CITY OF CUPERTINO-BUILDING DIVISIONry
• n ad r Nam : w N¢ APPLICATION / PERMIT '—G(--
R
A� T1t tV BUILDINGELECIRICA PLUMBING-M)CHANICAL CATEGORY CONTROL It
Architect/Engin
He.No:
Address:` 1 11 A. y FERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyeffirmthatlamlicensed under provisions of Chapter9(comment APPLIANCFSRESIDENTIAL JOB DESCRTPUON
�ng with Section 7000)of Di W salon 3 of the B urines and Professions Code,and my
license ie
In f dd(ePANELS
Licen�sCLt.#
Datel'y_ L_CantraGorJ`X.7- UP IQ 200 AMES
ARCHITECTS DECLAR ON 201-1000 AMPS AREA
oZ I understand my plea shall be used as public records,rrecords, °VER 1000 AMPS E D RI N $/�
N Z U Licensed Pmfessiotul SIGNS ELECTRICAL
Q Q re O tIam exempt
DECLARATION ` I T E R
E7, SPECIAL CIRCUIT/NISI
so, Iherebyaf(imnihatIam exempt(romthe Contractor's License Law for the
z Z..s following reason.(Section 7031.5,Business and Professions Code:My city or TEMP.METIER OR POLE INST. C DM
< �"' county which requorma pemdttocommuct,alter,Improve,demoWh,or repair
XSI G anysty mpdortoltalseuaMe,akorequbestheapphcantfwsurhpemdtto
Oc.O file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
w t. Contractors License Taw(Chapter 9(commencing with Section 7000)of Divi-
30`^ sion3 ofthe Business and Professimm Code)orthat he u exem therefromand SWIMMING POOL ELECTRIC VALUATION
yl the basis for the alleged exemption. My violation of Section 70315 by any
p� applicant for a permit subjects the applicant to a civil penalty of nor more than OUTLETSSWITCHES"FIXIVRES
$ five hundred dollars(SM. NEW RESIDENTIAL ELECTR
ZI,as owner of the property,or my employees with wages a their sok
comp �.FT. STORIES TYPE CONSTRUCTION'
ensak tion,will do the work,and the structure not or offered for
Dsale(Sec.7044,Bushes and Professions Code:The Contrad.e.Lt..law
G j$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES,UNITS
who does such work himse8 urthrough hisown employees,provided that such
improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
improvement issold w#hinoneyearofcomplelf theowner-builderwiB have .
thq*rdnof proving that hedid not build or improve for purpose ofsale.). 4aft fL(}jyfBTilIQ PElt? FEE
FFLOODOOD ZONE APN
uu 1, s ow er of the property,am exclusively contracting with licensed
contractors to construct the project(Sec 7044,Bushes and Prdsio
em Code: PERMIT ISSUANCE
The Contractor's License Taw does net apply to an owner of property who
Wilda or improves thereon,and who coMrada for such ptojects with a ALTER-DRAW k VENT-WATER(EA)
c JJLLt,radoKs)licensed pursuant to the Contractors License I. BACK FLOW PROTECT.DEVICE - '
lJ I am exempt under Sec. B k P C for this reasonFera
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• RECEIPT#
WORIGHAN COMPENSATION DECLARATION ��S PER TRAP SCHOOL TAX Y N
team
efflrm that I have a certificate of consent to eeBIn
- sure,ora RECEIPT#
sfertl team o(Workers'Comrure
peation lnsurancama difxed mS pythermf(Sec. GAEA.SYSTEM-I INCAOUTLM PARK FEE Y N
•�b 3 RFT_=#
Pdicy 1�P.TI I� /tea " _ GAS EA.SYSTEM-OOVER
Corrinan
III,
I1.•�—F-R��P BUILDING DIVISION FEES
/Ind—[`ilf'C-ified copy b heed y towith t sendled. GREASE/wDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertRied copy V tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-SCORN EA 200117 Date Recei t#
(This section need not be completed Bile,permit Is Intone hundred dollars
($100)orles.) WATER HEATER W/VENT/ELECTA ENERGY FEE Y_ N_
I certify that N the performance of the work for which this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of Califomu
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become sub}xt to the Workera'Compensation provisions of the Labor TOTAL:
re- Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby afRrmthatthemisa construction lendingagency for the perform- TOTAL: ELECTRIC FEE
Z ance of the workfor which thlspermit u issued fSer.3097,Civ.C.)
02 leader's NacrePLUMBING FEE
F Lender's Addres MICHANICAL PBRMCr: "RM
LL U IcertifythatlhavemadthbappUnConandkatethattheabovelnfom im a� MECHANICAL FEE
O W ismrrect.I agree tocomply with all city and muntyordirancesand state laws PERMIT ISSUANCE VV_ FEES PAID:
>_ IL relating to building mretrurtim,and hereby authotlu representatives of this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Revel t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against Nabi@ten,pdgments,crests and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
said Cityiocon ceofthe sting della pe mat.
AIR HANDLING IJIvTf(OVER 10,000CFM) CONSTRUCTION TAX
tvreof Applicant Contract t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS RIALSDIS SURE
Will the applicant or future building eatspaat store or handle hazardous HEATINGUN1T(T0lW,"BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _77 -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management Distrid7 ROLLER-COMP(3FI'OR 100,000 BTU) a
Yes
MN.
hyesmad the F rdous materials requirements underChapter 6.95 of BOILER-COMP(OVER 10gOW BTU)
the Californu Health k Safety Code,Sessions 25505,25533 and 75534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH.._ SQ.FT.
responsibility to not By the occupant of the requirements which most be mat 14� ��C'
pnorto issuance ofaComficate Of Occu �L
pancy. �/(s{ 91951
Owner ser or authorised agent Date — ISSUED 81/yR 11rV1AlIW{"r`
TOTAL:
OFFICE COPY