22610 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingProject Identification PERMTENO.
Building Address: 22610
/ooio /�I�fl� Clio D?r ���otRT.tia
noir. aide: one: APPLICA LION SUBMI 1-1 AL DA FE
oYe" CITY OF CUPERTINO-BUILDING DIVISION p- q
Contractor's Name: LIc.Nm APPLICATION /PERMIT O ^ t (�
BUR.DINC ELFiCTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL#
A,dumet/Fogineen Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtrea: PERMIT ISSUANCE L,V p ® Ds I�I ❑
LICF.NS EDCONTR under provisions
JOB L_
I hereby
7Oen thatlam W=3oficeresfheBuM mandsoffeWmsr9de,and APPUANCESRESIDENTIAL JOB DESCRIPTION
inensei !.hill force
diedn3o(the Budrmsaand Profodons Code,and my
license le In fuU force and e.0 PANELS1
DataLicense Claes Cop -
Date Contra
UPTO 200 AMM
ARCHITECT'S DECLARATION 201-IMOAMPS
M CZO Iundentand myplaseshaUbeused aspubBcrecerds. OVER 1000 AMPS , SQ.FT.FLOORAREA S/SQ.FT,
Fi Licendd Ikofenlonal SIGNS ELECTRICAL A L E D IN
<<,6(g OWNERtBUILDERDECLARATION SPECIALCIRCUIT/MISC MP TE
Zp, of Iherebya(firmthat lamexempt ER the DECLARATION
License Lw(othe
oo ppp following recon.(Section 7MIS,Business and Prefesalons Code:My city or
F,z countywhichrequimsapermittommtruegalteglmpmve,demilsh,orrnpalr TEMP MEM OR POLE INSf.
hg4 �7a anysuucwnprlarm lb lseuance,aha mqulm the app0ant lorsuch penNtm POWER DACES
U rile a signed statement that he s licensed pursuant to the prosslons of the
3µ Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC I
OJ dlon3oflhellusineseand ProfeniomCode)mthat hesexempitherefromand VALUATION
y.'•7 the bads for the alleged exemption. Any vlolatlon of Section 7031 S by any -o O
65 aPPliantloraperenlaubjects the applicant toa cisdl penalty of not morethan OUTLEWSWHCHFSFIXTURFS ll
a O five undmddollars(5500). SQFf. STORIES TYPE CONSTRUCTION
�m I,as owner of the property,or my employed with wages as[herr sole
NEW RESIDENTIAL ELECTR
colnZaatlon,will do the work,fes the structure Th.Contractors ittended o icensed for
Law
O dale snot ppy to anowandf properrty Codd:TheimproeLicense Law
�$ does not torn ownerof builds oyees,povidedrthatand such OCC.GROUP RES.UNITS
who
ovementsa n tIntended
nte dedorough Meown e.If,ho employees, ,thebr, ilding or
Improvements creno[Intendneyearfemdforsa ,,the runtuhe.rwill have TOTAL:
Improvement b oils wlthln oneysaro(compldiorythe owmr-W llderwlll have
thiII-tiurden of poising that he did net bund or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
C (J 1 as owner of the property,em exclusively contracting with licensed PERMIT ISSUANCE
contractors to cenauud the project(Sec.7044,Business and Professions Code:
The Contractor's Elected Law does not apply to an owner of property who ,M,gpg-DRAIN kVENT-WATER(EA)
Wild.or Impwn mu
rthereon, and who contract. for ch Iun)ects with e
ryBj(15W,)licensed Prdoutt to the Contractors License Law. - BACK FLOW PROTECT. FEE SUMMARY
ISI f am exempt under SB A,P C for this mason
OUTSIDE FEFq
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Qvndr Data RECEBT#
WORKINANIh IiNSATION DECLARATION FDCURF_S.PER TRAP SCI100L FAX Y N
❑1 hereby affirm that I have• Insurance
of content to opythereo or RECEIPT cedifiah ofWorkeus Compemationlruurance ora mrtl(led ropy thereof(Sec. GAS P.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)
Policy# RECEIPT#
CAS EA.SYSTEM-OVER I(EA)
Com any BUILDING DIVISION FRES
Certified copy s hercbytthe cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�CediOed ropy s Bled with
lM city Inspection division.
CERTIFICATE OF DfEMPEION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARY-STORM EA 200FT Date Recef t#
(TMlmsectlon need not be completed If the permit s Even.hundred dollars
(SIM).led`) WATER HEATER W/VENT/D.FOTR ENERGY FEE Y N
N
!certify that the per(omunmof the work forwhich this permit is lamed,
I shall not employ any person in any manner Is,as to become aubjed to the WATER SYSTEM/TREATING
Workers'Compensation laweo(Callfomia.Date PAID
licant
Z Z NOTICE TO APPLICAN'f:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. DBI¢ Recei t#
should become subject to the Warken'Campetuatlon provsionu ofthe Labor TOTAL:
N Code,you mat forthwith comply with such provisions or this permit shall be
j deemed revoked. BUILDING FEE
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE -
CL Iherebyafflrm chid there s i construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ante of the worklor which the permits blued(Sec.3097,Civ.C.)
V O Lenders Name PLUMBING FEE
LL F Lendce.Addrna QTY. MECHANICAL PERMIT LSE MECHANICALFEE
O W Imrifythat I have read this application and state that the above informed
Iscorrect.I agree to complywith all cityand county ordinances and date law. PERMIT ISSUANCE FEES PAID:
f
>. N relating to building construction,and hereby authorize representatives ofthts 2--f
�C/� 6Q-3
H Z city to enter upon the abova,mentlorad property for Inspection purpeacs. ALTERORADDTOMFCH. DRte—act R2Ce1 t#
(We)agree to save,Indemnify and keep harmlma the City of Cupedlno P
against liabilities,7 dgmenb,coda and expenses which may in anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: .U
against said Cityln consequence ofthegra nsoft molt AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
�741t-- I ?-/9--9 CONSTRUCTION TAX PAID:
Signature of ApplIcant/Contractor Data EXHAUSTHOOD(W/DICT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appllanl orfuture building occupant store or hand Is hazardous HEATING UNIT HO 100,000 BTU) 'Date ReceI t#
mdterlai as defined by the Cupertino MunidpaI Code,Chapter 9.12,and the
Health and Safety Code Sedion25532(a)7 ' HEATING UMT(OVCR 100,000 BTU) TOTAL: Soo
14 Yea k No
Wditties.pplicantcrfuWmbuildingoccupantumequlpMnt ordevim VFNIILATIONFAN(SINGLERF-qD) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OH'OR 100,000 BTU)
IYes ®Nd"
have read the herarp usmaterias requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
'The Califnml.Health&Safety Code,Sedlons 2550.5,25533 and 25534. I
undentandthaofthebuildingdoonotcurrcnllyh.w.tl nani,thatitsmy NEW RESIDENTIAL MECH. 9SQFr t l,�
empomiblllty to orally the occupant of the requirements which at be met
prior to Issuance of a Certificate of Occupan �as-
.L� �r77-4/ 117I��{CIAI/�
Owner or authorlud agent Data
TOTAL: ISSUED BY:
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