22773 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building a ed Identification I PERMIT NO.
Building Address; _ 22773
xw a(ne: s ��1 one;
ne
F /£ .20-VJ 7 CITY OF CUPERTIN48UILDING DIVISION Cj�-
• Contractor"Nam: Lie.No: APPLICATION / PERMIT (( CC
BUILDING-IB.FCTRICAI.PLUMBINC-MECHANICAL CATEGORY CONTROL N
Archltem/Ggineer. - Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PLUMB MELH
PERMITISSUANCE ❑ � ❑
LICENSED CONTRunder rDECLARATION
I hereby
ectionrmtO)ofDt siolicensed 3ofthe usinemandPovisions ffesgwsrodm and nc APPLIANCES-RESIDENTIAL JOB DESCRR'I'ION
inenseI in
forceardefelon3o(the Buclnessand Prolndona Code,and my
license le In full force and diem. PANELS
License Class LLCM •1/-/-[�\--' / "V%B e-
Date - Con[nmar '
ARCHITECI'S DECLARATION 201-IOW AMPS
cez I understand my plane@hall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA B/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
<<�-el OWNER-BUILDER DECLARATION SPECULCBtCUIT/MLSC
Iherebyaffirmthatlamexempt fromthe Contndor.LicemeLaseforthe
pp following reason.(Section 7031.5,Business and Professions Code:My O city or Z t- TEMP.METER OR POLE]NST.
c
p,a wnty which requires permit tocevtmm,altcy Improve,demolbh,or repair
y a an ystmdumpdortoltslswance,alsomquimstheappliontforsuchpermltto POWER DEVICES
Oa V file a signed statement that he b licensed pursuant to the provbimro of the
Contractors License Law(Chapter9(mmmencingwith Section 7f10O)ofDivi.
NOp don3o/the Businessand ProfeesionsCods)orthm hels exempt therefromand SWUIMING POOL ELECTRIC ypLUgT1ON O
the basis fort alleged exemption. Any violation of Stolon 70315 by any OUTLETSSWITCHESFIXNRES D 0 0
0 appucantf 'JJ=1 subJects the applicant to a civil penally of not more than
liveh d erof@(5500), NEW RESIDENTIAL ELECTR SQ.FC. SIO Es TYPE CONSTRUCTION
u owner of the property,or and he employee with wages r thele dole
M cempnnsalion,wuldothe s,andkfessim structure,ode:Th.lancet Contactor.orofferedLar
M 0 sale(Sec.apply
to art ow er Profmiaru who
Gomnmoes LiceIhere slaw
does whorl apply loan imaulo(prough who builds orimproveswRand
uch OCC.GROUP RES.UMTS
GG whodaeuuch are not m@ededoraugh Msown ee ale.Itemployees,
owevrthebthat lelingh
improvement issold tintendedoro(feces pl&io.theh ev budderwilingoe TOTAL:
Improvement beold withlnoneyearo(completion,theowner-bu0derwill have
tl�urden of proving that he did am bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L J FLOOD ZONE APN
4 as owner of the property, S exclusively contracting with licensedCWt: PFRMI.I.I�UANCE
romnmanet no?.Ltmm the .doe(Bee 7 apply
Budness and Professions Code: •d V
The[Dor improves
es the Lew dare not apply tct an r nersuch m Property who ALTER-DRAIN k VENT•WATER MA)
Wilds t Improvse thereon,and who cemnde for e L p(ojeds with a
Ljractor(eexempted punuantt eC ry oro LicenseC for
BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
LjI t exempt ca r c. B&P C lar thio reason
vDRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N
Own Date I-a— RFCEU'f N
WO f E RATION DECLAR ION pp(TQRE&PER TEPP 0)' SCIjOOL TA% Y N
❑I he, affirm Ih have a certificate of canssnl to .IX
ora �• V RFGEB'I'M
certifleateof Worken'C petuatlon Luunnnora certlfledcepythereo!(Stt'
3800,Lab Cd S CAEA,SYSTEM-1 INC.40I1TLEI5 PARK EFF. Y N
Policy p RECE97
R
CoAS F.A.EA.SYSTM-OVER 4(FA) BUILDING DIV
ISION FEESmrtified
copy b hereby tci d. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V(fled withh the
e tlty Isujuctlon division.
CERTIFICATE OF EXEMPTION FROM WORKER S' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei tH
(IhiHnctlan need not m completed tithe permit V(Drone hundred dollen
(5100)arfy th WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify thatothe person
any
he crawok(ors to become
permit l@IssuM,
I shall not employ any pawn In any manner at as to become eubjem to the WAS SYSTEM/TREATING
orke 'Compensatlon Laws of California.Date PAID
O z PPnBox.t NEWRESIDENTIALPLMB. SQFT. Date RCcei IN
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
1" should become•ubjcet to the Workers'Compemation providers,ofthe Labor TOTAL:
c W Code,you=at forthwith comply wl[hsueh provlsioroor this permit shall he O
9 teemed revoked.
BUI �.,FEE
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE d
I hereby affirm that there V a ce.bodies lending agency for the perlmon, ELECTRIC FEE
7 z ance of the work far which this permit is lasund(Sec.3097,Civ.C.) TOTAL - Q
1) O Lender.NamePLUMBING FEE . D
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertltythat l havereadthbeppuatianand datethat theabovelnformatlm
6 ucerrem,Iagree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives oflhle
F Z city to enter upon the above-mentioned property for impemlon purposes. ALTLR OR ADD 7O MECH. Date Recei tic
_ (We)agree to save,IndemNfy an d keep harMess the City of Cupertino
agaimt llabiuties,judgments,cesteand expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,11DO CFM) SUBTOTAL'
against said City N mnwqu ence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,0W CFM) CONSTRUCTION TAX
Signatunof Applicant/Contremor Dat. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appuant or future building occupant store or handle hazardous HEATING UNTT(TO 100,000 BTU)
material as defired by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei tR
Health and Safety Cadc_kpMn 25532(a)I HEATING UNIT(OVER I W,OW BTU) TOTAL:
❑Yee IYI Na
Will the applic.... tmtt.rodingocdefine use if.Bay Area devices VENTILATION PAN(SINGLL•RESID) ISSUANCE DATE
which eMthazardous airirict arab as defined by the Bay Area Air
Quality Management DL elm BORER-COMP pI-B'DRIW,000 BTU AAD
Yes o rffrr���R
Ihave readthe lo.I ousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER IW,000BTU) Q
the Califomlallealth k SafetyCede,Semiow25505,25533 and 25534.1 au pj 1(g Q 9x71
un nd thatif the building does not currently have a tenant,that It lsmy, NEW RE9DENTIAL MECH. SQ.FT. y�3 ff p0
po unity to notify the occupant of the requirements which moat be met /d@�
rior Issuance late of Occupancy. Vulapa sasr.
(/40V Y/
ncrora t ri n Data
TOTAL: ISSUED BY: CC.
OFFICE COPY