22447 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prate Identification 7 PERMIT NO.
Burning Address: 22447
io3sa PALO cv
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on . A
VIelLY�VA.Av OEN f, eIG CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lie.No: APPLICATION /PERMIT6 — ��
BUILDING-FLECTRICALP1, MBING-MECHANICAL CATT;1 CONTROL M
ArcMtect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: SA mE ' PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
herebyaffrm that lam Rcensed under provisions ofChapte
r9(mmmrnc- APPLIANCFSRFSIDENTIAL s 06 JOB DPSCRIPDON
IrgwithScdlon 7000)of Division 3 ofthe Businessand Pro(esslonsCode,and my
license Is In full tome and effect. PANELS
License Class Lie.It P
Date Contractor UP TO 2DO AMPS h IT '\e IA.,O We
ARCHITECT'S DECLARATION 2014000 AMPS
oy Iundentand my plans shall W used as public records. OVER IODO AMPS SQ.Fr.FLOORAREA $/SQ.Fr.
CO
b`j Licensed Professional SIGNS ELECTRICAL !�Tn
�¢ OWNER-BUILDER DECLARATION 3 SPECIALCIRCUH/MLSC 'l z,sv
p„ Ihereby affirm that l amexempt from the Contractors License law for the
PO ... following motion.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
q f cauntywhichrequi aper ttommtmMMter,impmve,de=o h,ormpair
ESm�� anystrucum,pectin Its issuance,alsorequim,theappllmnt for such permit to POWER DEVICES
ES r4 file a signed statement that he Is licensed pursuant to the provisions;of the
a Contractor;License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION O
O Bion 3ofthe Business and Profevlons Code)orthat he is exempt therefromand U•
the basis for the alleged exemption. Any violation of Section 7RH5 by any OUTLETSSWIMIJES-FIXTURESj'j
&9<T.
applicant(Or.permit subjects the applicant to a civil perakyofndmorethan e o v
p, a fiehundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FI'. SPOICES =CONSTRUCTION
.. 1,as owner of the property,or my employees with wages as their sole
C compevatlon,willdothe work andthuwcture bnotintendedor offered for
5 <p sale(&c.7004 Business and Professions Code The CorbactoJs License Law
does not apply to an owner d propery,who Wilda or Improves thereon,and OCC.GROUP RFS.UNITS
e. whodoesauchworkhmeelforthraugh hisownemployees,provided that such
Improvements arc not Intended oroffered for sale.If,however,thebuilding or TOTAL: .S
improvement issold within ane ycarofcomplel loo,the owner-bullderwill have
d,ttiurden of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLODDZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sm 70K Business and Pro(esalors Code:
The Contmcta/s License law does not apply to an owner of property who
Wilds or improves thereon,and who contracts for such pLojeds ALTER-DRAIN k VFM-WATER(FA)with a . OD
�yBtT+&or(.)Bcensed pursuanttothe Comractor;Lkxnse Law. BACK FLOWI'ROTECT.DEVICE FEE SUMMARY
L-JI arty exempt under Se B k P C for this reasonOUTSIDE
YL/CGQ �J'o I ( SANITARY Y N
w•
./�. On ` �') Date /%/�'/q� DRAINS FLOOR ROOF,AREA,COND. RECEIPT=
WORKMAN COMPENSATI NDECLARATION py%rUREg,PER TRAP SCI IDOL TAX Y_ N
❑I hereby af(Irm that 1 have a certificate of consent to sell-Insure,ora RECEIPT Y
comflesteo(Workers'Compsmationlrsursece ma artitied copytherm((Sec. GAS EA.SYSTEM-]INCA OUTLETS '7 PARK FEE Y N
3BOO,Lab C.) OC• UD
Policy I GAS EA.SYSTEM-0VER d(E 3) RECEIPT a
Cam any BUILDING DI VISION FEES
Certified copy is hereby furnished GREASE/INDUSiRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SRM En xpFT Date Reed IN
ra
(Thl..ection need t be completed If the permit is toromSEWER-SANITARY-STORMhundred dollars
(SIM)orleae') WATER IIFATFR W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work(orwhich this permit is blued,
I shall not employ any person In any manner so as to become subjcet to the WATER SYSTEM/TREATING
Works'Compensation laws of California.Date . D D PAID
Workers'
O Z Applicant NEWRESIDENITALPLMB. SQ.Fr. Date Rett'] tq
Z O NOTICETOAPPLICANT:ILafter making this Certificateot Exemption,you
should become subject to the Workers'Compewtlon provblom of the LaW r TOTAL:
N Code,you must forthwith comply with such provisiomorthis permit shall beBUILDING r0 dv
deemed revoked.
III CONSTRUCTION LENDING AGENCY SEISMIC FEE a
tl O E Ihereby affirm that there is a construction lending agency for the perform TOTAL: ,0 ELECTRIC FEE 3 -S
7 0 an"'
of the work for which this permit is Issued(Sec.3097,Civ.CJ PLUMBING FEE
(� O Lender;Name
U. F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U ]mAifythatf M1avemadthbapplimtbnandstatethattheaWve I f0rmation
0� FEES PAID:
OW iscorrect.I agree to comply with all city,and county ordinanmandstate laws ' PERMIT ISSUANCE �•
0. relating tobuliding construction,and Wreby authorize representatives of this
H V) city to enter upon the aWve-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date ReceIFIN
_ (We)agree to save,indemnify an d keep harndcm the City of Cupertino
against AIR HANDLING I1MT(1'010,00(1 CFM)t liabilities,judgments,costsand expenses which may In any way accrue SUBTOTAL: S
against said City in consequence of the granting of this permit
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sigwturco ppOcont/Comrador DateE%HAl15T HOOD(W/DILA r CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO IDQ000 BTU) Date Recel tq
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the //.1
I lealth and Safety Code Section 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL: It
❑Yes MNo
Will the applicant or(alum building occupantVENTILATION FAN RFSID)occupant use equipment or devices ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air PA J1
Quality Ma iugement Dist rid? BOILER-COMP OHP OR 100,ON BTU) ✓11�IY
4 Yes No �A
have read lM1e Fazar u9 materials requirements under Chapter 6.95 of BOILER-COMP(DVIR 100,000 BTU) f6��
the Celife,nUllealthkSafeiy Corte,Sediors25505,25533and25530. I - 11 ik 19
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. S2.FT
responsibility to ratify the occupant of the requirtments which most be met C*prior to Issuance of a Certificate otOrcupancy. *of CUPIIIfl
TOTAL:
Owner or authorized agent Date ISSUED �'�`+�'
vvv •••
OFFICE COPY