23158 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: - ^3 1 5 n
22050 �T G lSJ }V(
Uwners ame US one:
ZS-3 xC(-Oq' .CITY OF CUPERTINO-BUILDING DIVISION
Contra sN, NT� ^ `tSoe APPLICATION / PERMIT
BUILDINGELECTRICALnLTMBINC MECHANICAL CAlFGORY C
Architect/ RI ear. Lie.No: -
W�Vti�t—C I I i' . PEE ' -BUILDING PEM9977
IV.
'-`` `` QTY . 'ELECTRICPERMIT
Address I�� r ICD �J '�� pI72MIT ISSUANCE .. r
%UMI1 1,11-CH
LICENSED CONTRACTOR'S DECLARATION -
Iherebyaffirm that l am licensed under provisions of Chapter 9(commrnc APP LIANCESRESIDENTIAL BDFSC PION
ogwftlimnwh infull7000)of d affect
ofthe BuslnessandPro(ealonaCode,and my
lirenx is In full defleLiz#ct. d PANdS
Llcen C Contr 2. '
Date Contractor
ARCHITECPS DECLARATION 201.1000 AMPS
K OVER IMO AMPS IT.FLOOR AREA
{pp{uu OC2C Iundentand my plans shall used as records. "�
E U Licensed Professional SIGNS ELECTRICAL VP
�< OWNER-BUILDER DECLARATION . SPECIAL CRU
CT/MISC
zpO., 6 I hercbyaffirmihat l amexempt from the Contractor's License Lawforthe ' _ -
O q following reason.(Section 70115,Business and Professions Code:Any city or
FZ�'ry county which requlresa permit tocmntrua,alter,improve,dennlish,orrepalr TEMP.METER ORPOLEINST.,
q`� 7 anystruRurc pdorto lte Issuance,also requlrestheappllant(oreuch perMtto
t5 file a signed statement that he Is licensed punuant to the provisions of the POWER DEVICES
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION
f;,30J slon3ofthegusincas and Pro(eslom Code)eathbrc
at he SWIMMING POOL ELECTRIC
yd.•77 the basis for the alleged exemption. Any violation of Section 70315 by any
<
applicant for permit sub' thea applicant to a civil nal of net more than ))UTLETS SWiTCHESFI%TURES
PP Pe Iects PP penalty
a five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTRSQ.17. STORIES TYPECONSTRUCTION
7a compemation,will do the work and thestruciure Is not Intended or offered for '
O saIn IS,.7044,Business and Pmfesalom Code:The Contractors License Law
3$ does not apply to an owner of property who builds or Improves t hereon,and OCC. RFS.UNITS
who does such work himself or through his own employees,provided that such _
Improvements arc not intended oroffered forsale.If,howevepthe building or T ►�
Improvement issold withlnoneyearofcompl0ioMthe owner-buiiderwlll have
tje�urdenofpmving that he did rot Wild orimprove forpurpaacofuk.). QTY. ', PLUMBING PERMIT' FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to consWct the project(Sec.7044.Business and Professions Code: �� t
The Commences License Law does not apply to an owner of property who ALTER-DGINA VENT- _
Wilda or Improves thereon, and who contracts for such p(ujecM1 with a WATER ffA) _ t'
�g6[Tacior(s)Ilansed pursuant to the Conlratlor's Llcenee Law. BACK F7AWPROT[CT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this mason
DRAINS FLOOR RODE,AREA,COND. . SANITARY Y N
Owner - Dale RECE[PT#
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to aelGmoo m,or
RECEIPT M
certifiateufWorken'Compensation lmurance ora certified copythereof(Sac.
3800,Lab C.) GAS EA
3800, INCA OUTLETS PARK FEC Y N
Policy 0 GAS G.SYSTEM-OVER 4(FA) RECEE''r 8
Coo�r!ny BULDINGOIVIS FEES
91Certifled copy b hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLA CI-ty FEE I
Certified copy bfiled with the city inspection division. {r' L I?O
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI
COMPENSATION INSURANCE - TTTJJJIII
(Thlasectlon readout becomted plelithe permit Lsforane hundred dollars SEINERSANITARY-STORM PA.20017. CCCI laY
($10(0orlm.) WATER HEATER W/VENT/ELLCTR E Y N
I certify that In the performance of the weak forwhlch this permit is issued,
1 shall not employ any person In any runner so a to become subject to the WATER SYSIRM/TRGTING
Workeri Compensation Laws of Callfomla.Date PAID
O'Z
Applicant
Z O NOTICE TO APPLICANT:If,after rtaking this Certificate of Exemption,you NEWRESIDFNIIALPLMB. SQ.FT. Date Recei I#
Hshould become subject me worker'Comet reation provisions of the Labor TOTAL:
X W Code,you=at forthwith comply with such pmwW.m or this permit shall be BUILDING 'E _ ^T
deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE '
Iherebyaffirmthat them is a construction lendingagency forthe perform- ELECTRIC FEE
Z anof the work!or which this permit is issued(Sec.3097,Civ.Q T
U 4 Ierdera Name - - - PLUMBINGFEE '
LL H Leader.Addre, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mriBythat l have read thisappliation and statethatthe above information
1 '.correct.I agme to comply with all city and county ordinances and state laws . PERMRISSUANCE FEES PAID:
} relating to building construction,and hereby authorlae representatives oflhts '
F Z city to enter upon the above.mentlonM property for Inspection purposes. 'ALTERORADDTOMEC)i. Date Recef Ill
(We)agree to save,Indemnify d keep harMess the City of Cupertino
Ilabilltles,judgnenla,ro s and expenses which may in anywayaceme AIR HANDLING UNIT(TO 10,000CPM) SUBTOTAL:
g
a ns au Inco sequen that amin o hls permit.
��` AIR HANDLING UM000 UNIT 10, CFM)• CONSTRUCTION TAX
Sigmmreo ApplContractor Dote IXFAUS'T HOOD(W/UUCT) CONSTRUCTION TAX PAI
HA .
' ' lA RDOUS MATERIALS DISCLOSURE
Will.I as efiran or ytheCrcbulldingaicipan ode, hapten 9.hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t0
motorial as defined W the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade�x-S.�ection 25532G)7 HEATING OMT(OVER I W,000 BTU TOTAL:
❑ Ym 1�l No
1Vili the applicant o�tom building occupant use equipment or devices VFNRLATION FAN(SINGLE RESN) RSkp`&B DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dlelrlct7 BOILER-COMP OHP OR 100,0M BTU '
❑Yes ❑Na ' 1992
• Ihavc read Health
Safet materialsemon.25Sntsunder Chapter.1 of BOILER-COMP(OVER 100,000 BTU)' FEB 2j
the understand
Health ASafety Code,Stolons25505,25533and25534.1
urdcrstailitythat lithe thbuilding does not hurgll..h t.a9enaphthatb Limy NEW RESIDLMIAL M[iCFf.
rcaponsibll ante ofa Cehe ocapantouparryulrements which must he met , CIl"Y UI' �aUf Lr stYV.
priorm Issuance u(a Certlfaate olOmpancy. I — '
Owner or authorized agent Date R ISZEDB
TOTAL:
OFFICE COPY
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