22449 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
Build Ing Add m
, �►� " t --zon 22449
one: p
CITY OF CUPERTINO-BUILDING DIVISION G
• can d w ' Lic.No: APPLICATION I PERMIT — C I
Architect/Engineer. Llc.No: BUILDING-ELECTMCAL-PLUMBINC MECHANICAL CATEGORY CONTROL N
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address P - POMITISSUANCB LVBLUNJ UbL � El
CONTRACTOR'S DECLARA ION '�J
I herebyaf(bm that l am licensed under provisions ofChapler 9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sedion7000)o(Dlvlelon3ofthe Buslneuand ProfesslonsCocie,and my ^ ^ rx �/
licence lain lull farce and died. PANELS IIIA•
Date
Class Uc.N .
Date Contndor 201111W AMPS
ARCHITECTS DECLARATION
07. I understand my plana shall be used as public records OVER1000AMPS FLOOR AREA $/SQ.FT.
CO
Licensed Profemtonal SiGNSELECTRICAL nAYM '
6
OWNER,R MILDER DECLARATION
I"n SPECULCIltCU1T MISC
owing reM.ason.
mionhat mexem)rt(rotheossa d Prefdorb License:LawAny lm the
lollowtngreason.(Section 7031S,Business and Pimp one Code:Anydryer
� 1-.� TLMP.MEI'D20R POLE INST.
� anystm�ntympflrtois penance requ alltheapmvgdenwchper to
anya Agnere t t.ment that
he Is Worequbeatheat to it. revisions of t e POWER DEVICES
O �
file a signed statement that he V Breneed pursuant to the provisions a( the
Contractor',License Law(Chapter9(commencing with Section 7000)of Owl-
SWIMMINGCn SWIMMING POOL ELECTRIC Q sWn3ofthe Buslneuand ProfeulonsCode)orehat hebexempttherefromand h1 VALUATIOf4
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESFIX .TURES 0 D OU 0 O
applicant for a permit subjects the applicant toa civil penalty of not momthan
live hundred delta.(SM. NEW RESIDENTIAL ELECTR
I,as owner of the property, SQ.T• RIES TYPECONSTRUCTION
Z ❑ p perry,or my employees with wages r offered
woe
compensation,But isc the work,and thestrudurehIsom ntraMad or offered far
M4 sale(Sec.761y Buslnau and Profenlona Code:The Contranots Lirensc Uw
$$ does net apply to an owner of property who Wilds or improves lhercon,and OCC.GROUP RES.UNITS
who doeasuchworkhimself orthrough his own employees,provided that such / O
improvements arc not Intended oro(fered for sale.If,however,thebullding or TOTAL: 1
Improvement V wld wlI Inoneyearofcompletion,the owner-builderwlll have
UI{-krrden of proving that he did not Wild or improve for purpose of ala.). QTY, PLUMBING PERMIT FEE
Lf FLOOD ZONE APN
7,as owner of the property,am exclusively 1vely contracting with limmedCode: PERMIT ISSUANCE
TheconContractor's
rons sac the project(Sm.appy BusNeuand of property
Code:
The Comrade/a License Lew does cad apply ct an owner of Property who ALTER-DRAIN&VENT-WATER(EA)
Wilds t r Imprensa thereon, and who matters for se L p(ojeM with a
cpRKaaorG)licensed pursuant S.C..
the Contractor.License plow. FEE SUMMARY
I am ex )rt oder Sea B&P C (or lM1b reuen BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner
Data
RECEE'T N
4 RKMANCOMP S TIO DECLARA
pl hereby affirm that I have a certificate of consent to eel!-insure,ora FIXTURF3 PER TRAP C.Q O CHOOL TAX RECEE'T N
rertlfeste of Worken'Compensatlon Insurance ora certified mpythemo((Sec. GAS EA.SYSfEM.1 INCAOUTLETS PARK FEE Y N
3800,Lab C.)
Policy# — RECEIPT#
GAS EA.SYSTEM-OVER d(EA)Comm any - BUILDING DIVISION FEES
11 Certified copy La herebyfamished.the city
CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
rL�—JCertlEed ropy tB filed with the dry Impectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY•
(This Rection need not be completed if the permit isforone hundred dollars STORM EA.2001717, Date Remi t#
(S100)orlem.) WATER HEATER W/VENT/6ECTA ENERGY FEE Y N
I certi/ythat In the performance of thework for which this permit 1.issued,
1 shall nm om / emaon In any ma r n u to bee a e t the WATER SYSTEM/TREATING
Weaken Comp a n�eDale_� PAID
O Z Applicant NEWRESIDENTIAL PIMB. SQFf. Date Revel [#
Z O NOUCETO PLICANTal,after making this Certificatt of Exemption,you
should become subject to the Workers'Compensation previsions ofthe Labor - TOTAL:
P:
W Code,you=atfMhwith comply with such provlalons orthis permit shall be U D CO
EE
LU j deemed revoked. '
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafil that there is a construction lending agency for the pedoro- ELECTRIC FEE
0 Z ansae the work(or which this permit Is Loved(Sec.3097N. ,Civ.C.)
TOTAL:
LL O L od&r Add a PLUMBING FEE OD
ly L) enderspahatl QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W emd.Ia agree
ptywth ad this licetionand dcou ty ordinances
tion laws
G brorrect.lagree to comply wlthalldtyand county ordinancesand pale laws PERMITISSUANCE PEES PAID:
} Nrelating to building construction,and herebyauthorlae representativeaafthis
F Z city toenterupon the abovo-mentlored property for Inspection purposes. TERORADDTOMECH. Dale Revel [#
— (We)agree to save,Indemrdty and keep harodeu the City of Cupertino
against llabilities,judgments,was and expenses which may In anywayamue Al IANDLING UNIT(TO 10,OD0 ) SUBTOTAL:
against said City In consequence of the granting of this permit. AIR DUNG UNIT(OVER ,000CFM) CONSTRUCTION TAX
Signature of Appliomt/Contractor Date EXHAUB OOD(W/D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplirant orfutum building occupant store orhandle haeardous HFATING UN (TO ,BOO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Flea lth and Safety Code Sed 32(x)7 HEATING UNIT 8100,000 BTU) TOTAL:
Yes
o
Rill the applicant or lure building occupant use equipment or devims VFNfILAT1 FAN(NS 'GLE RESID) ISSUANCE DATE
which emit hasamdous air rontaminants as defined by the Bay Area Air �L
Quality Management D'tdc[ BOILER- MPOHPORI 000BTU) ME)
4 Yee
havernia the M1asa o�malsr Sectio ,25505,5533 anhapter. 1 of BOIL COMP(OVER IW, BTU) Jul.
the Califunderstand
at If Health
building
uil Cade,Sect1ountly have
a tenant,
that I 171991
undentandlhatn notify
the occupant not a currentlyea lsnahL that it met RISIDENT'IAL MCCIi. SQ.IT'
rnponslblllty tondity t�he�o�ccj�py�a occupant of the requlmments which must W met was a.�
Lwory. /_�{ 0 Y9 K.yu aal�
Owner or authorlud agent t MIT
TOTAL: ISSUEDBY:�_��� GG
OFFICE COPY