22281 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
BuROding A ' . � w - 22281
cancra one: , -
N�QSU.C¢.X - CITY OF CUPERTINO-BUILDINGDIVISION
C°manor°Na^e: y Lic.N°: . APPLICATION /PERMIT
SC1J U �IC.C•` • BUILDING CATEGORY CONTROL p
Architc�Fls/ neer. iZECTRICALPLUMBINGMECHAMCAL
Ii430.T Llc.No:
` y QTY ELECTRIC PERMIT," t., FEE - 'BUILDING PERMIT INFO
Addrc.c 2.25 7N l R .TIO PERMITISSUANCE .. ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION •
I hereby affirm that l am licensed under provisions of Chapter 9(commenc MPLIAN'CESRESIDENTIAL ]OB DEIKA IO
ingwith Section 7000)0f Dlvlsl0n3 ofthe Businessand ProfeselonsCods,and my L
license IB In full form and effect. \ PANELS
ec �r
LlcesClass LICM _ 1
Date Contranor s
ARCHITECT'S DECLARATION N)1"1000 AMPS
gyPpp±±re 20 I understand my plans shat be used as public records. \ OVER1ODDAMPS - SQ.ITT.FLOOR AREA S/SQ.FL.
E Od p Licensed Professional � SIGNSELECTRICAL
<6 OWNER-HOLDER DECLARATION «u
2 R�& y 'N SPECIAL OHCUIT/MLSC
o I hereb affirm that lam exempt from the Contranor's License Law for the '
OZ following reason.election 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. " '
C E'�q( countywhlch requlreea permhmcorotrun,alter,improve,demolish,orrcpalr - - ' t
•� anystrunure priart°Its Issuance,also requlresthe applicant forsuch permit to '� POWER DEVICES 2U T
file a signed statement that he h licensed pursuant t°the provisions of the v
O re Contractor.License law(Chapter 9(commencing with Section 7000)of Divi-
si
on3o(theBuslness..dProfesslonsCode)0rthat he is exempt thercfermand SWIMMING POOL ELECTRIC
m .LID,
< the basis for the alleged exemption. Any violation of Senion 70315 by any \ OtMETSSWITCFESFTJTUBES'
applicant for a permit subject the applicant to a civil penalty of net more than
C. live undrcd dollars(S500): NEW RESIDEMTALELECTR EQ.FT,
�I,as owner of the property, - STORIES TYPE CONSTRUCTION
p perry,or my employee with wage. their dole
G compensation,willdo Business and k,and
sslons unurehnot
Contractor or License
d for
La. I 11Z KVA -TiT"S�01-• _ ' �^
Q .1.(Sec.7654 Business end Professlor,.Code:The Contractors Llceree law
S$ docs enn.pply t0 an owner of property who builds or improves thereon,and t OCC.GROUP WS.—UNITS
whodoessuchworkhlmdelforlhrough hisownemployees,provided that such
Improverrcnlsare not Intended oroffesedtorsals.If,howevepthebulldingor
Improvement issold withlnoneyearotcompletion,lhe owner-Waiderwlll have
thrden of proving that hedid not build orimprove for purpose°tdakJ. QTY. +, ', PLUMBING PERMIT,.% CFEE'" FEB DZONE MIN
r�Lias owner of the property;am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7056,Business and Pmfemiom Cade:
'Me Confranor.License Law cions net apply to an owner of property who ALTER-DRAIN is VEIN-WATER(FA)
Wilds or Improes vthereon, and who dentfor ed for supcojeee with a
anor(s)Burned pursuant to the ContnnP or's License Law. - . ;FEE SUMMARY
I am exempt under Sec. B.(4 C 15for this mason BACK FLOW PROTECT.DEVICE
Owner Date' DRAINFLOOR ROOF,AREA,COND. SANITARY Y_ N�
S
WORKMANCOMPENSATIONDECLARATIONRECEIPT#
E31ffl1 hereby a .that 1 have a urM
tiBcate of c"race[to self-meam,°r a MES'STRAP SCHOOL TAX Y N
certificate of Workers Compenation lruu rano or a¢rtlfkd copy thereof IS,,, RECEIPT# -
3800,Lab C.) GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N_
Poll Is
Com any GAS EA.SYSTEM-OVER<(EA) - BUILOINO DfVI510N FITC
Certified copy In herebyth the icy CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
❑CertlBM copy hfiled with the city Inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE SEWER-SAMTARY-STORM G.700FT. Da[C ReIX9l t#
(This section need net W completed lithe permit h forone hundred dollar
(41DO)
rtifythat
a - WATER HFAT'FRW/VFNT'/ELDCTR ENERGY FEE Y N
Ice not lhatmtany person finny mannhe ekfo as to whichthiseenNtle leered, —
I shall not employ any person in any mannerso u to become subject to the WATER SYSIT�M/TREATING
' Workers'Compensation Lawn of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date RCtt'i t#
.Z O, NOTICETO APPLICANT:If,after making this Certificate of Exemption,you SQ.IT.
should become subject to the Workers'Compensation provw=of the Labor TOTAL:
N Code,you must fort hwlth comply with such provisos or this permit shall be t
lL > deemed revoked. - BUILDING FEE
CL O - CONSTRUCTION LENDING AGENCY - SEISMIC PEE
Ihembyaffirm that lhcrc ha covwsunlon lending agenry forth.perform TOTAL: ELECTRIC FEE
O ante of the workfor which this permit is hed(Sec.3097,CIv.C.)
O under.Name - - PLUMBINGFEE
Iy F Under.Add. QTv. MECHANICAL'PERv'IT FEE' MECHANICAL FEE
O,W I<ertitythatlhave read thhappllcutionand watelhat the above information
a corren.I agree to comply with all city,and county ordinances and state laws PERMIT ISSUANCE FEE—PAID:
} 0. elan ng to building construction,and hereby authorlee representatives of this
•r Z
city inenter upon the Above-mentioned property for inspersion Purposes. ALTER OR ADDTOMECH. Date
V — (We)agree to save,Indemnify and keep harmless the City of Cupertino - Receipt#
against llabillties,judgment,castaand ex reran which maymarywayacuue AIRHANDLINGUNfI'(r010,000CFkU - SUBTOTAL:
against told City in consequence of ing of this permit.
F� zZ AIR HANDLING UNIT(OVER I O,ODO CIM) CONSTRUCTION TAX
Signature of Applicant/Cont'.d.' a EXHAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERI 5 SCLOSURE
Wllltheapplant or future building .toe or handle havardous BEATING UNIT ITO 100,0DO BTU) Date RCCCI f#
materialasdefined by the Cupertino Municipal Code,Chapter9.17,and the - t -
- ❑ Ynd Safety Co�Scclloor2S537(a)7 t P I'IEATING UNIT(OVER 100,000 BTU) _ TOTAL{.
Will the applicant or cue building occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCEDATE '
which emit lb..rdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHPOR IOO,IXU B'['[n, Y' A I,p
'?have
Yro N°
havead Healthe h
err Tet mode, ections25505,25533as requirements Chapter. 1 of BOILER-COMP(OVER 100,0(p Olin FEB O
the California Health k tldlry Code,5enlons75505,ve a tenant,
- r 9 Ij92
responsibility
es orstantl that rotie"ullding doe..(tcurrently the eqin, entsw which
that It met NEW RESIDENTIAL MECH. SQ.17 f� I
p6ortolbuanc0ofa Ce eiateofNot moancqulmsrcnlawhich must be rrct /x �1
priorm issuance ofd Certiflate ofOmpanq. CITY Or �iUhtYI111YU
'Owner or authoriad agent Date
•• - NOTAL: ISSUED BY�
OFFICE COPY