22845 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PE(MITNO.
Building Address: 22845
943 Miller Ave .
wners ams: - one:
CITY OF CUPERTINO-BUILDING DIVISION J M�
C;;IA f�.&..t� Biti,eh- e"1 a APPLICATION I PERMIT 61 "1. 5'l
'. Arrhl yBUILDINGELECTMCAL-PLUMBINGMECHAMCAL CATEGORY CONTROL Y
No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. El,�] PLUMB MUCH
PERMITISSUANCE ❑ ❑
-by a LICENSED CONTRACTOR'S DECLARATION 1* say IM1ereecidon7Bite0 ehat I 0)ofDi lken3ofthe uMne WoneofCssims9(rommmy APPLIANCES-RESIDENTIAL OB DESC
incese1Section 700))of Dlvfect. thegumnessandlarofnslon•Cade,and my 1y
litnse Is in full force and effect. PANELS L`{�
License
Clam LIF.
Data -E-4'�3-C t r' Grl AMPS
ARCHITECPSDECLAR , ION
Wz Iunderstand my plans shall be used as public recoeda OVER IOW AMPS �SQ. -Al $/SQ.FT.
00
Licensed Professional SIGNS ELECTRICAL NX�
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC P �,
itldl .f hereby affirm that I am exempt/coin the d Professions
Limine law fothe city mr
Q oo following reawn.(SMion 78115,Business and Profmkm Code:My city er =�
PZ B rountywM1kh rcqulresapemdt tomnslrod,ater,lmprove,demoWh,orrepar TEMP.METE2ORPOLE INST.
'y 6mystcture pdortoltsIssuance,also rcquireethe applicant/or such permit to
O mfile a signed statement that he b licensed Forwent to the provisions of the IV WF.R DEVICES DAT
FEµ(� Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi-
OS doOofthe Businessand Pro(essionsCode)orthahebexempt lherefromVALUATIONand WMMNCIOOLEECTRC
•A the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjeiathe applicant to a civil penalty of net more than OUTLETSSWITCHESEXTUREq
fl6undred dollars($500).
u r,as owner of the property,or my employers with wages as their Bala - W RESIDENTIAL ELECTR SQFT, STORIES TYFE CONSTRUCTION
III...... compensation,willdolhe work,and thestrodure Isnot Intended or offered for
O sale&c.7066,Busbress and Profeesioro Code:The Contradol•License Law
$ doe.nut apply to an owner of property who builds or Improves thereon and OCC.GROUP RES UNITS
whodoessuchworkhimselforthrmgh hianwnemployees,provided that such
Improvements are not intended oroflered(orsale.If however,thebuilding or TOTAL:
improvement hwld within omyearofcompleWn theowner-bullderw It have
tlt, rdmo/provingthat he did mat build or Improve(orpurpowolaakJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE - APN
�j I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mrutrua ec
the project(S .7044,Business and Prm(essions Code:
The Contractor's Litman Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-
builds or improves,thereon, and who contracts for such plojecu with a WATER(EA)
"bacteria)licensed pursuant to the Contndbr's License Law. BACI(FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt order Sec. B&P C for this mwn
Owner Dae
DRAINS FLOOR ROOF,AREA,GOND. SANITARY 'Y— N WORK MAN COMPENSATION DECLRECEIPT-ARATION IV(TURES-PER TRAP SCIiO0LTAX Y N
❑I hereby affirm that I a • lrtme of consent m self-Insure,ora RECEIPT N
3801liceteolWarken'Compewtlonlnsurant ora trtified copy thereof(Sec.
3800,,lab CJ GAS EA.SYSTEM-1 INC.4 OUTLETS PARKME - Y N
P.Cc Y 1012144222 GAS EA.SYSTEM-OVER 4 MA) BUILDING DIVISION FEES
RECEIPT N
Com any
91CerCertitlfled copyththhed. - GREASE/INDUSML WASTE INTERCEPTOR. PLANCKECKFEE
fied ropy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWF&SANITARY-STORM EA.X00171•. Date Remi t#
(Thlawdlon need rad becamplded It the permit k(orom hundred dollars
(fl W)orlesha WATER HEATER W/VENT/ELFL'.TR ENERGYFEE Y N
I llrat emp oyin anyhe edomunt of tormnerhe work for as
to become
esubjeermit Is waved, Y .
—
I shake nm employ any person in any manner w as to become subject to the WATER SYSTIM/TREATING
Worlicant mpensatlon Lawn of California Date PAID
Applicant NEW RESIDENTIAL PLMB. SOFT. Date RcCel t#
Z 0 NOTICE TO APPLICANT:U,after making this Cediflcateof ExemptioM you
CC eh.ldb..subjMtothe Workers Compenmtimpmvbiom ofthe Labor TOTAL:
f— Code,you=at forthwith comply with such provisions orthle permit shall be
W > deemed revoked. •'E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I herebyaflrmthat there is a construction lerdingagency for the perform, ELECTRIC FEE
Z ant of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL:
(> Q Lender'.Name PLUMBINGFEE
L F L nder�Addme.. QTY;:` ;,MECHANICAL PERMIT FEE MECHANI E
O w trtlythatlhavetadthisapplicationanddatethattheaboveInformation 15 . 0 FEESPAIT
(L bmrmd.I agreeto complywlth all city and county ordinance and gate laws PERMIT ISSUANCE
r W relating to building construction,and lemby ewhod,ce representatives of this .. -
H Z city to enter upon the above-mentioned property for lmpedion purposes. ALTER OR ADD 7O MECH.
— (We)agree to save,indemnify an d keep harmkcas the City of CupertinoRecei t#
against liabilities,judgmtre,coaaand expenses whkh may In anyweyacxxue AIR HANDLING UNIT(TO I0,QI0 CFM) 14 SUBTOTAL:
age lost said City in consequent a!the granting of this permit.
AIR HANDLING UNIT(OVER IO,000CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllitheappil Iorfutumbuildingomrpantstore orhandle hacardoes HEATINGUMT(rO1W,0D0BTU) Dale Recei t#
materials.defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA .
Rill
1 Yin UN.
Illthe applicahacand use ro eltua occupant use Atord¢vice VENTILATION FAN(SINGLE REED) ISSUANCE DATE
which eMahazardousabrict? rants ate de0ned by the Bay Arca Air
Quality Management Dbtdd7 BOILER-COMP(3)POR 100,000 BTU)
Yea ((''��I No
i have readtheha>ar�0usrmledala rquiremenbunderChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the Glifomla Health&Safety Code,Sectlmns25%5,25S33and25536.1 ('+s B '
understandthallfth bub ild) not corrcnty have a tenant,that l( my NEW RESIDENTIAL MECH. SQFT L`"' Gq
rcapot t .ocmpan tihc rcmarts which mint be met
pr o e m a
9LS49W
��JL'�
mer or authodand agent ate -
MTAL: 2 4 . O OY
OFFICE COPY