22282 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:- '� JO IE T" W,4,r 22282
seers ossa:b/ ypn�e:�
YEc 4h CITY OFCUPERTINO-BUILDING DIVISION
Contractors Name": /p Lie.N. APPLICATION /PERMIT l v L
OWNG/� BU `� yIv BMDINC-ELECMUCALI-WHING-MECHANICAL CATEGORY CONTROL L�
Architect/Engl L�p(Io V
P— G/ "' QTY I ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: t o. 6 BmN tal4r J;14%J � � � (2cao
PO MITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflmnthat l am Rcmaed under poewsiones ner. APPLIANCESRESDENTAL JOBDESC
`.
Ingwith Ser11on7OW)of Divlsion3dithe Businemand Profeaon
el .Code,andmy GB yl.Vt�T6-at-N'O
Ilmnee lain full force and died. PANELS' P
License Clam Lm.N 'x
Date Contractor
ARCHITECTS DECLARATION 201-1WOAMPS -
OO O I understand my pia®shall be used as public omords. OVER 1000 AMPS - SQ.FT,FLOOR AREA .S/SQ.FF.
c - - SIGNS ELECTRICAL 7 'v 3�-
Licensed Prolenioml e
6E OWNER-BUILDER DECLARATION, � � t
71.., .I Eembyalflrmthat l am exempt frwnthe Contractor's License law for the SPECIAL CIRCUIT/MISC •t
Z/3iI]J
oo following reason.(SeR1on 9LD1S,Busmen and Pro(emione Code:Mydty or
O Z ?TMP.METER OR POLE IN
� muntruenum raquhe.apemdttocoorequi .the aproes,demolbh,ermit ir
to
106
any.tmcturc priortolt.Iamance,also requlresthe appBcant(or such permit to ]OWER DEVICES, l
E5 file a signed statement that he b licensed pursuant to the provisions of the
3wI�• Contractor's License Law(Chapter 9(commencing with Section 7000)of Diet- IO
SWIMMINGOLELECTRIC
N�OI eion3oflhc Business and ProtessloiuCode)orthet hebexemptthercfromand VALUATION f
a.3 the barb for the alleged exemption. Any t violation of Section 70315 by any rf I OUTLE.[SSWf7.CM;SF[X.TURFS I(�L'�� e!��f>��r D Q
app Brant for.permit ealleed exempts applicant vioa ion ofenalty
not mors t than .•C•
f1 h red doll en(5500). NEW RES[DFN77AL ELECTR SQFF.
�n as owner of the property,or my employees with wages as their sole STOLES TYPECONSTRUCTION'. TYPECONSTRUCTION
t cop satlonwRidothework,andthestructure bnotintended or offered for
j 5 O sale(Se.709M1,Business and Professions Code:The Contractors License law
I $$ does not apply to an owner of property who builds or Improves thereon,and - C ' .[JNTI'S
who doessuch work himself orthrough his own employees,provided that such
t improvemontsarc notintencied oroffered formic.11,however,lhebuildingor TOTAL; %APN Improvement usuldwilhln oneyearofcomplatlorytheownenbuilderwBl have
thr*rden of proving that hedid not build orlmprove for purpmeofaem.). QTY, PLUMBING PERMIT , .
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE', 1 /
I contraction to comUuct the project(Sea 7094,Bearenand Profemlons Code:
t s.. The Contractor's License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p;okcta with a - _
"�iR(TTactor(.)licensed punwnt to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
- LJ I am exempt under Sea B Its ve
P C for this man
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ -
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_
❑I hereby affirm that I have i certificate of consent to opytherrc,(s e t RECEII'f N
3800,certifILab C.Workeri Comperuatlan liuurana oracertified copy thereof(sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFER Y N
350Q lab C.)
Policy N GAS EA.SYSTEM-OVER d(EA) RECEIPT M
Com any BUILDING DIVISION FEES
MCertlfledoo b herebyfurnished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
�Cedlfled copyb(Iled with the city Inspection division. ( J >
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID J0(1.4111
COMPENSATION INSURANCE SEWER- STORM-STORM FA 200FT Date Recei t#
(TMesectlon need nu W completed i!1 W permit b(or one hundred dollars
(5100)arlen.) subject
HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ �-ID
I certify that m rmce the perfoanof the wok far which this permit c hoed,
WATER
shall not employ any person In any manner as u to become bjM to the WAT R SYSTEM/TREATING
Worompeneation Laws of California. Dam PAID _
Z Z Applicantlicant O NOTICE TO NEWRESIDENTIALPLMS. SQ.FF.. at Ccei t#
Z APPLICANT: after mating thisCertificate ofFm F rN
should become subject to the Workers Compensation provikhms ofthe Labor 1 TAL:N Code,yomu remost forthwith comply withsuch peuvoikout rthb pemmtahallbe DU
j deeed voked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE Q TZa
a, 3 thereby affirmthat there bacenstmetlon lendingagenry forthe perform- TOTAL: ELECTRIC FEE
M Z anne of se
the work foi which this permit is Issued(Sec.3097,Civ.C.) a
V O Lander.Name PLUMBING FEE Ct0
LL L-e.derb Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W
O I certifythat l have read this application and slanthat theabove lnfom
utlon rI�'3
C bcomect.lagrestocomply with all city and county ordinances and state laws PERMIT ISSUANCE '4(f SPA
FEEID:
>- relating to building construction,ind hereby authorlu representatives ofthis - ¢
2 city to enter upon the above-mentioned property for inspection purpose.. I ALTER OR ADD TO MECH. l�CW
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino • - Date Reeel [#
against liabilities,judgments,mks and expenses which may in anywayaccrue AIR HANDLING UNIT ITO 10,000CLM) SUBTOTAL:
ago Wtmid CB in anm ofthegraotmgofthI.permit• CONSTRUCTION TAX
_ AIR HANDLING UNIT(OVER IO,OIIOCIM)
SI natum o(Appliaot/Con a ar Date EXHAUST HOOD(W/DITCD CONSTRUCTION TAX PAID:
HA7AR Ot ERI SDISCLOSURE -
Wllltheapplicantorlinure building occupant atom or handle hazardous ]'[EATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Cods,Chapter 9.12,and the 'Date ReceI t#
Health and Safety Code Section 25532(a)7 HEATING UMT(OVER 100,000 BTU) TOTAL• s
❑Y. N No
Will theapplicznt orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdom air contaminants as defined by the Bay Arca Air -
QualityManagementDistrict? i BOILER-COMP OFIP OR IOgIXq BTLn
4Yes Q❑No
hll read the haaardou.nutedab rcqulrcmcnb under Chapter 6.95 of BOILER-COMP(OVIR 700,000 BTU)
the( fernla Health k Safety Code,Sections 25505,25533 and 25539. I D
understand that lithe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF
raponsiblllty to notify theonvp.rt of the requirements which most be met AUG Q�
prior to imua nee of a Certificate of Occupancy. r�
Owner or authorised agent Date
TOTAL: 2A,lZ/ ISSUED BY:_
OFFICE COPY