22272 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuBding Address: n n n�f n
7537 EACH #�COSSoM GGG / G
s w loned A A
f-kbic, s CITY OF CUPERTINO-BUILDING DIVISION
Contncur'e Name: 3,.ucc.N°: APPLICATION /PERMIT -�
ISSEE COry Iry x //37,3 BUJLDING-ELECTRICALF-UMBING-MSCI IAMCAL CATEGORY CONTROL
Amhard/Engineer. Lic.No:
QTY ELECTRIC PERM IT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ K
LICF.NSEDCONTR under provisions
RATION
Ihereby Seeti fimn70 that lam licensed hellud assannsof sedonsr9(commec APFLIANCFSRESIDENTIAL JOB DESCRIrDON
IngwehSM1onfc.;V and effeon3o(1he Bus+r�essand FmfessloruCode,and my s (e7 / I,
s license Is in full f and effect. i .y PANELS
License C mZLk.
Dated Ip�_ContraRor [,�q�
rr 1 1 ARCHITECT'S DECLARATION i 701-1000 AMPS
D 14wpwz I understand my plawsha8 be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
V ofLicensed Professional SIGNSELECTRICAL L E D I IV
w OWNER-BUILDER DECLARATION
1n SI'ECL1LGfRGU1T,MLSC P T E R
f" .�a Ihcrcbyaffinnthat lam exempt form the Convactor'slicrnse Law for the
CYNI
X,SIL F- following reason."Section 7031.5,Business and Professions Code:Any city or TIME.METER OR POLE INST.
..� ywhlchrequl apert ttommtrucl,alter,Impmve,demolLh,orrepalr !! /� /
YDS anystructurs Orlon)its Issuance,also requlresthe applicant forsuch permit to POWER DEVICES / [O
C file a signed statement that he is licensed pursuant to the provisioru of the
Owl Contractor's License Law(Chapter 9(commencing with Sedion 7000)of Did. SWFAMING POOL ELECTRIC
30 sion3 ofthe Buauessand Profassum Code)arthat bilis exem therefromand VALUATION
Y2 S the basis for the alleged exemption. Any violation of Section 7031.5 by any
Y r OUTLETSFS
SWITCHHXTURES
app8ant fora prrtNt sub)rctstheappecant to a tiv1l pemltyof na morethan
(5 D
five hundred dollars M. NEW RESIDENTIAL ELECTR SQ.R. STORIESTYPECONSTRUCTION
�7¢^ ❑1,as owner of the property,or my employees with wages as their sok
compensationwtlldothe work and the structure is not intended or offered for
5 O aak(Sec.MdM,Businrss and Profession Cade:TM Contractors LIcemelaw
$ does not apply to an owner of property who builds or improve thereon,and
5^ whodoessuchworkhlmself orthrough hlsown employees,provided thatsuch OCC.GROUI' RES.UNITS
Improverearts are not Intended oroffered forsxle.If,however,thebullding or TOTAL:
Improvement 6sold withinoneyearofcompldiontheownerbu8derwill have
th,�a'den of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with Rcansed PERMITISSUANCE
contractors to construct the project(Sec 7014,Business and Professi)e Code:
The Contractor's License Law don not apply to an owner of property who
bulWa or Improves thereon,and who contracts fee such plojeds with a ALTER-DRAIN&VENT-WATER(EA)
a.Rs)licensed pursuant to the Contractor's License Law. FEE SUMMARY
IJ I am exempt under Sec. B& P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT'N
ggWOR KMAN COMPENSATION DECLARATION F1XTVRES PER TRAP SCHOOLTAX Y N—
❑I hereby afftrm that I have a certificate of consent to aelf-insure,or a RECEIPT N
certificate of Workers'Compensation Wurance ora defiled copy thereof(Sec.
x3800,L bC.) GAS EA.5YSTQ.T-1 WC.40ITII.EIS PARK FEE Y_ N_
RECEIPT N
policy p
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
om any
eertified copy is hereby furnished. EPTOR PLANCHECK FEE
Cedifed ta
copy 6 filed with 5the day pe<lon division. GREASE/WDUSIRL WASTEINTERC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIURM EA.200IFT. Date Recei tll
(This section need not be complcted If the permit 6 for one hundred dollars
(5100)°rlcsa) WATER HEATER W/VENT/ELGCTR ENERGYFEE Y_ N_
I certify that In the performance of the work for which this permit is 6s ed,
1 shall not employ any person In any manner sou be subject to the WATER SYSTEM/TREATING
Workers'C)m)dAsatigltlaww q( I Data
O
PAID
Z Apph.nt fir'-1liisx n..�tLL 7 j NEWRESIDFMTALPIMB. SQ%T. Date Recei til
Z O NOTICE TO PL
CANT,If,after makingthis Certifkate of Exemption,you
shwld become aubjrR to the Workers'Compenatlon provlalom of the Labor TOTAL:
tl) Codayou=at forthwith complywlthsuch provisionsorth6permit shall be BUILDING "E Z.0
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC ITB
d Ihereby afflrrothat there 6 a coetroctton lending agency for the perform- TOTAL ELECTRIC FEE
7 Z ante of the work for whieh this permit 6 issued(Sae 3097,Civ.C.) PLUMBING FEE
() O Lenders Name TY. MECHANICAL PERMIT FEB
LL f Lender.Address Q MECHANICAL FEE �• P
U I.nifythatl havercadth6appltratlon.nd statethattheab°ve Information
O W 6corred.I agrmto complywith all etyand county ordinances and state laws PERMIT ISSUANCE Zf1 FEES PAID:
} S relating to building construction,and hereby authorim representatives of this
cit t entero n the abovcmeneomd property for lv t ALTER OR ADD TO MECH. Date Receiptit
F 2 y ° P° P pertY Pec[°t purposes. -(�
(We).galti to save,Indemnify an d keepharmlesswhich the 1.any Cupertino MR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL'
V against llabl isles,judgments,comaand expense which may In any way accrue
ag wtaa city Inc sryuence ere ammg)nh6 permu'G CONSTRUCTION TAX{/s AIR UNIT 0C M)
(OVER IO,00
Signature fApplkant/Contractor /Date '/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea licant or(cure Ildin ooeu antstoreorhandleharardous HEA TING UNIT(TO 100,000 BTU)
rP B P Date Recci to
materia las Safety Cod,,51 rtino Municipal Coda Chapter 9.12,and the
Health and Safety C)dr Ice 25532(.)7 HEATING UNIT(OVER l00,OW BTU) TOTAL: V v
❑Yea . No
Wllitheapplican )'(cure building occupant use equipment or devices VFNDLATION FAN(SINGLE BESIDE ISSUANCE DATE
which Manaementa mimntsasdellmd by the Bay Area Air agar
which a Management
Distoc 7 BOR.FRCOMP 17HPpR I W,IXp 8Tl!)
[?Yes No JUN 7 f�f�{{kk,,(e���
have read the hail r s materials rcgWrcments underChapter 6.95 of BOILER-COMP(OV[R 1fA,000BN) J N + 'KNE
the California Health&Safety Code,Se as 75505,255533 and 25534.1
understand that If the building does not corrently have a tenant,that it is my N'EW RESIDENTIAL MECH. SQ.FT.
respom biloccupantity t°notify the occupant of the requirements
which must be mat City of Cuperton
priori ua e)faCertificate of Ocmpanry.
Owner or authorhmd agent Dat D ISSlJBD1Y'j1 s VY. UV C ,
TOTAL: a-�
OFFICE COPY