22519 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proen Identification PERMIT NO.
R llding Addre„' fig sL� tia��l - 22519
nen ,.me: one:
` ` 259• 1.5 99 CITY OF CUPERTINO-BUILDING DIVISION
Mar- ., Rate, w r l
Contract rI Name: —}' s LIc.W APPLICATION/PERMIT
n , J DSC P {M S S BUR,DING-ELECTRICAL PLUM BING-ME-CIIAMCAL CATEGORY CONTROL I
Architect/Engineer. Lle.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add... PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirce that l am licensed under provisions of Chapter9(conunn APPLIANCESRFRIDENTIAL ]OBD ON
Ingwith S dion701D)of Dlvislon3 ofthe Buslneasand Profe,e..Code,and my
Iica 111n lu8 ayyd effect. PANELS
LlcanseChm t Ifs. 6 1 �
Date��_Contractor O /Nis.�at r
ARCHITECTS DECLARATION 201'1000 AMPS
M ]unde�mJl ndmyplaruq�yB be'�As public records. OVERIGOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
5+`�LY /1/
SIGNS ELECTRICAL
LicensedTrofemlo/ru�l�
6 OWNER-BUILDER DECLARATION
rn 3SPECIAL CIRCUIT/MISE
,F• Ihereby a(firmthat lam exempt fromthe Contractors License law for the
o Q following reason.(Section 70115,Business and Professions Code:Any city or
county which requires.permit to construct,alter Improve,demolish,or repair ]'EMP.METER OR POLE IN57.
N§� anystrucamprl.rtola Issuance,also requires the applicant for uch permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provIsom lof the
�w Contractors License Law(Chapter 9(commencing with Sect1on70W)of Dwi- SWIMMING POOL ELECTRIC
O alon3of the Business and Profemlov Code)mthe he Is exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any
0
applicant fare permit sub)nb the applicant to a civil penalty of not morethan OUTLETS-SWITCHES-FIXTURES
live hundreddollarsof the W). NEW RESIDENTIAL ELECTR SQFT, STORIES TYPE CONSTRUCTION
<, ❑I,as owner of the properly,or he employee with wages r thele dale
C compensation,will do Businethewwkand xaaf. atrode:Th Contractorot or d far
Law
O dale(Sec.apply
to An ow andf property Code:TheContractorsLlamalaw
r�8 does and
whodot apply torn oanerofpropertywho
nempoHmprwnted that
much OCC.CROUP RES.UMTS
wprovementses such amwork hlmsededoroughedow or ale.If oweprovidedihatsuch
Improvementsarcnet intended earofoo platioe.ILhowever deer ill have TOTAL:
Improvement Iswld within aneycar ofcompletlon,the owner-budderwlll have
tllRkurelen of preving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively Omer—ung with Il vows FLOOD LONE APN
contractors to cowlruct the project(Sec.7074,Business and Profemloro Code: PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilda or Improvas thereon,and who contracts for such p(ojects with a tFEE SUMMARY
� actor(s)licensed pursuant to the Contractor'.License Law, BACK FLOW PROTECT.DEVICE I am exempt under Sec. B k P C for thin mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECF7IT p
WORKMAN COMPENSATION DECLARATION FIXTRdE&PER TRAP SCIBO)L TAX Y N_
❑I teof affirm that I have a oertl0nte of.o dif to self-tnsure,ora M RECD,X
certificate of Workers Camperuallon lrsunnm ora aorti(rd copy memo((See. GAS F.A.SYSTEM-1 INCA OUTLETS 2W PARKFEE Y N
Polis # C.)
Policy p GAS EA.SYSTEM-OVER 4IRA) DING DIV
Com any BUILDING DIVISION FEES
�Certifed copy Is herebyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city IospeHon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWERSANrrARYSTORM FA 200Fr Date R22e tit
(Thlseection need not be completed If the permit Is(atone hundred dollars
(S1I0) tify th WATERHEATER W/VENT/ELFCTR ENERGY FEE Y N
ImHfymat Nthe person
of meaner forwhichwastobthiseemdtis Rothe
I shall not employ any person in any runner n as m become subject to the WATER SYSTEM/TREATING
Workers Compensation Uwe of California. Date PAID
OZ Applicant
Z 0NOTICE TO APPLICANT:If,a fter nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei tilt
should became subFct to the Workers'Compensation provision of the Labor TOTAL:
0 Code,you moat forthwith comply with such previs om orthis permit shall be
deemed revoked. BUILDING M 0 ' CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafOrm that there Is a construction lending agency forthe performs ELECTRIC FEE
Z acre of the work for which this pernek Is C.)Issued(Sec.3097,Cle. TOTAL:
V O U.der.Name - PLUMBING FEE 7
LLF- lender'.Address QTY. MECHANICAL PERMIT ' FEE MECHANICAL FEE
OW Imrtl(ylhat l have read thisapplicationand statemat theabove infomution
1 Iscormet.I agreeto compiywith aIldty.nd countyordinanocaand state laws PERMITISSUANCE FEES PAID:
>. W relating tobuilding construction,and hembyauth.roompresentativesofthb
F city to enter upon the above-mentioned property for WpecHon purposes, ALTER OR ADDTOMECH.
Z
_ (We)agree to save,Indeann and keep harmless the City of Cupertino Date Recei tit
against liabilities,7adgments,cusband expenses which may In anywayaranue AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL:
against said City in conaeyuenca of the granting of this permit.
Sig2� _ T�/•�, AIR 1iANDLINCUMT(OVFR IO,000CFM) CONSTRUCTIONTAX
natures of Applicant/Contractor y( O '? Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplicarat orfutum building occupant store or he ad le harardou, HEATING UNIT(TO 100,000 BTU) Date Recel IN
material as dented by the Cupertino Municipal Code,Chapter 9.1Z and the
Ilnith and Safety Cade Section 25532(e)? HEATING UNIT(OVER 100,000 BTU) TOTAL: •QJ
[—] Ye. MN.
Willtheapplicant or future building occupant use equipment ordevices VENTILATION VAN(SINGLE RESID) ISSUANCE DATE
which emit bavrdous SG coos tedrants as de0ned by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
yea n No
have read the h jN mutenab mqulrementsundcrChapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) PAM
the C71femla Health k Safety Cade,Sections 25505,25533 and 25534. I
understand that if the building does not mrrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. as
roponslbillly to notify the occupant of the requirements which must be met �� LJ-..aC
prior to iseuann of a Certificate of Occupancy.
Owner or aulhorieed agent Date N.
TOTAL: ISSUED RY�wwr � +
OFFICE COPY