22198 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALLPOINT PEN ONLY
Building Project Identification - PFRMITNO.
Building Address: -J22-198
o N e — / S�
JAL DATE
'Iliek,r _ TLG �. ,CITY OF CUPERTINO-BUILDING DIVISION ]—_ 2
Can &or'. LI°Nre APPLICATION I PERMIT
Arch ect/Engineer. Lic.No:. BUILDING-ELECTRICAI.PLUMBING-MECHAMCAL CATFAORY CONTROI•# -
Q'rY �ELECTRICPERMIT• FE�E.a� BUILDING PERMIT INFO
Address: PERM TISSUANCE L„f/ �[(�, ❑ ❑
_ LICENSED CONTRACTOR'S DECLARATION L.J�S
I hereby afftrm that l am licensed under provisions of Chapter 9(co. APPLIANCESRESIDENTIAL JOB DESCRIPTIONIng with Scotlon 7000)of Division 3 ofthe Business and Pm(egons Code,andmy -
license o In fuB force and effect. PANELS
License Class Lle.p •i S��^-h 1
Date Contractor UP TO 200AMPS
ARCHITECT'S DECLARATION 201-1000A.MP9
DO lundentand my phns ehaB be used upubecreunrds. OVERIODOAMPS, SQ.FT.FLOOR AREA S/SQ.Fr.
ti I Licensed Professional - SIGNS ELECTRICAL B
<6 OWNER-BUILDER DECLARATION IL �N
ti 4 SPECIALCIRCUIT/MISC ED ' R V
02-9
-G owing ytount. that lam31.5, from the Contractor's License Law for he t,..�
ZOZO fogowingich mclftenb ermitt,Businenand Professions Code:Mydty or 77MP.METER ORPOLE INSf. 1P
K countywhich rcqulreea perMttoconstroct,altep Improve,dertnloh,orrepalr ,
O UTER
anystmcture prlorto its Issuance,also requtmstheapplicant for such permit to POWER DEVICES
, file a signed stabreent that he is licensed pursuant to the provisions of the o 7
��Pp99 w Contractors License Law(Chapter 9(unmmendng with Section 70(0)of Dlvl- //�
Fy3
sion3ofthe Businensnd Pmfenlons Code)orthalhel3cumpttherefmmand SWIMMING POOL ELECTRIC -
< the basis for the alleged exemption. Any ,violation of Section 70315 by any OUTLETSSWITCHESHXTURES
applicant fora permit subjects the applicant to a elvil penalty of not more than IU
q qqq five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQFr. RII5 TYPECONSTRUCTION
Cd$^ E]1,as owner of the property,or my employees with wages as their sole _
t compensation,will do the work and the structure is not Intended or offered for
D sole(Sec.7614,Business and Pmofaislons Code:The Cmdr cte.License Law
$$ does not apply to an owner of property who builds or improves thereon,and .00C:GROUT' RES.UNITS
EE whodoes such work himself or through hlsown employces,provided that such .
Improvements amount intended muttered forsale.If,howevegthebulldogor TOTAL: -
improvement osoldwI inoneyearofcompletimytheowner-buil erwill hdve
rden of proving that he did not build or Improve for pue olsab. FLOOD). QTY. PLUMBING PERMIT FEE D ZDNE,. APN
� rpos
L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec 7014,Business and Professions Code:
The Contactors LI as Lw does nal pply to an owner of property who ALTER-DRAW&VEM-WATER(PA)
builds nth n, d unnenm such ptokm with a - FEE SUMMARY
ct a need nu of tnc[�wL.w. BACK FLAW PROTECT.DEVICE OUTSIDE FEESx c. reason DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT#
WORKMANCOMPENSATIONDE RATION FO(IIJRES pgg TRAP SCITOOL TA% Y_•N_
❑I hereby affirm that I have i certificate of consent to self-Inure,or RECFLT#
cenifleateof Worken'Compensatlonlns mnceora certlHed ropythereo((Sec. GAS EA.SYSTEM-1 INC.40I1TLET5 PARK FEE Y N
3900,Lb C.) - RECEIPT Policy# GAS EA.SYSTEM-OVER 4(EA)
Com any -BUILDING DIVISION FEES
❑�cenl0ed copy o herebyfuml,hed. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE [
❑Certified unity 1,filed with the city Inspection dlvldon. 30,
CERTIFICATE OF FXLTTPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7(IOFr, Dale Recel t#
(Thiess.loa need nn bn complMed if tM permit b foronc hundred dollan -
(51OD)orlea,.) I WATER HEATER W/VENT/ELECTR 'ENERGY FEE Y N
I w,ifythat he the Performance of thework forwhich this permit is bound,
1 shall not employ any person In any manner a u to become ub)ect to the WATER SYsrEm/TREATING
Workers Compenatlon Laws of Cai fomla.Date PAID
0 Z Applicant - NEW RESIDENTIAL PLMB. SQ.FT. Dale Revel t#
Z O NOUCETOAPPLICANT:If,after makingthis Certificate of Exemptbn,you
should become subject to the Wmiuma Compc.tlun provisions of the Labor TOTAL:
Code,you most forthwith comply with such provisions or this permit shall be BUILDING 00
W j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY. SEISMIC FEE CD
1 hercbyafftrmthat there Is a construction lendingagenq(orthe per(orr, TOTAL. ELECTRIC FEE .,r••0
0 anceofthe work!orwhlch this permit is oeted(Sce.3097,C1v.C.)
U lenders Name PLUMBING FEE
F Lender.Address QTY. MECHANICAL PERMIT FEE
LL U 'I redifythat I have read thoapplicationand gatetha/the abovelnformallon MECHANICAL FEE
0 W b corncL l agree to comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID:
} C relating to building construction,and hereby authorise representatives of this
I.. Z2' a
theabove-mcnlload props fm Wpection purpose. ALTER OR ADD TO MECH.
save,Inaemnlry an d keep Men the Ci of Cupertino Date" , R6eei t#. ti
jdg no, sand pen which y soywayamue AIR HANDLING UNIT(TO 10,000CAM) SUBTOTAL'nco ofthe a n tF _ _ AIRHANDLING UNIT(OVER IBW0CFM) CONSTRUCTION TAX
l sot/ o ret to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOU9 MATERIALS DISCV.,
Will the applicant or future building occupant store orhandleharamdous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
mamrbl a,defined by the Cupenine,MuNdpal Code,Chapter 9.i2 and the p
Hiealthmi Safety Code Se
action 25537(a)T HEATING UMT(OVER 100,000 BTU) TOTAL:
❑ Yrs No
Will thea Bca sot or tum building oro tusee 1 rent or devices VENTILATION rAN(SINGLE RESID)
PP R Pin he P ISSU�AN(; DATE
hicheMlhavardomalr ronnMvnn as defined by the Day Arca Air SOMERCOMP 0HPOR100,000B
dilly Management District? Ttn
i�J Ye. No
7huveread Health
Safety
Code,
garlic.25505,25533
and 25534.
553of BOILER-COMP(OVER 100,000 077J) h c) VP the C.Iffchain nmb Health&Safety Code,Sectlonently have a tenant,
that it
Ifai' V llu"v1a
understand that.the ifythldingdoes hot a .qre iyma tatenan.,tbt met NEW RESIDENTIAL MECH. SQ.FT.
prto Tuanmofafytheuteoftoftherequlremenlewhlch rtw,t beret City �es no
prior to Lnuance ofd CertiOcatc ofOttupancy. � 4
Ownerorauthodudagent Date Q
TOTAL: ISSUED BY: o
OFFICE COPY
I,