22297 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlfkallon /� `` .' ,,���� PERMITNOO.. //'�^/ �^1
Building Address:�C•]G S fig D ow RI-L-L- �' 22297
2 9 7
ame: one: APPLICATMIT399VI'MALDTTE-
CITY OF CUPERTINO-BUILDING DIVISION
Contracto:sName: LIc.N. APPLICATION / PERMIT
BUILDING-ELECTRICA MUMBING-MECFIAMCAL CATEGORY CONTROL
Architect/Engineer: Lk.No: b
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE co LICENSED CONTRACTOR'S DECLARATION
gµithS aRlm that lam L'm3ofheBuemsed r rovisions andPffmimsrodco a APPLIANCESRESIpENTWL �4/
In IthSmion7000)o(Dlviton3 catch#Butrsssand ProfesslonaCode,and \
license 1.1.s (onx and effect PANELS ��
License Claes Lic.p
Data Contactor IM IQ 2DO AMM
ARCHITECTS DECLARATION 201-1000AMPS
��qq
Ore p7" m
Iundentand myplamahallbeused aspublicrerds. OVERIOBOAMPS 5Q.FF.FLOOR AREA $/SQ.FL
Lkcnaed Pro(esslonsl SIGNSELECTIUCAL
Ne, / 1r�O(J,J ri Lt
OamWNER-BUILDER DECLARATION 1. CJ f`'lJh' ZJL OYJ
Ihercby afRrmthatlexemptfromtheContratorb Llrense law lou the SPECIAL CIRCIRT/MISC '1CU6
oo '� following reason.(Section 7001,5,Business and Professions Code:Any cityor
FZI"'t9 countywhich reclaims a permit toconstrict,alter,improve,demelbh,orrepair TEMP.METER OR POLE INST.
y9d any stricture prierto its lswance,aLso requirestheappticant(orsuch pe
mdtto
O file a signed statement that he es licensed pursuant to the proebiom of the POWER DEVICES
3O� Contractor's License Law(Chapter 9(mmmiencing with Section 700))of Diet- SWIMMING POOL ELECTRIC
alon3 of the Business and Professloru Code)orthm hats exempt therefromand VALUATION
4,1 the basis for the alleged exemption. Any violation of Section 70715 by any /!.^� 1 /� t
uvl 0<5
-pp
llcantfor a permit subetseheapplicant toe civil-#wily of net room than
�V OUTLETS-SWITCHES-FIXTURES VVt
c, �� five hundred dollars($SM. NEW RESIDENTIAL ELECTR
--�n ❑I,as owwr Of[be property,or my employee with wage as that sole �'FT STORIES T1TE CONS[kUCT10N
compensation,willdotbe work andthe stmctem b not Intended or offered for q
5 O dmsnee. pplytos owmd pmpeow ho Wilde Comps m here law
$ does not apply to an owner of propertywho builds or Improve thereon,and a
who doe eats are nohimself orthedoroffe Msowne.If,ho n,provided that such rs �, C R R 5
improvements intendneyearferedfolm lmtheh mer- flubuilefing orhave T07AL: liv III I R
11
Improvenentbsold withinoneyearofcomplelbn,theowner-buBderwlll have
rdenof proving that he did not build or Improve forpurposeofsale.). QTY, PLUMBING PERMIT FLOOD ZONE APN
,as owner of the pmpety,am exclusively contracting with licensed PERMIT ISSUANCE
ntraton to construct the project(Sec.7014,Business and Professions Code:
I Contne ctoes License Law donot apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
builds or improve thereon, and who contracts tl
for such pkojes with a
ff,IIST,ctor-)licensed panda.to the Conitatols Lima.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L_l1 am exempt under Sec B k P C for this reason
Owner Data DRAINS FLOOR ROOF,AREA,CON-. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECEIPT#
01 hereby affirm that I have a wrtificate of consent to self-insure,or a FIXTURES PER TRV' SCHOOL TAX Y N_
confirms of Workers Compensation Insurance ora certified copythereof(Sec. RECEIPT#
M00,Lab C.) GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FIX Y N
Polley# RECEIPT p
Com any GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
CertBled copy b hereby furnbhed.
Certified copy is filed with the city Wpetion division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASE TRAP ppjp6'2'�-ql CaZ�(�
COMPENSATION INSURANCE
(fhis Mionneednmbecomplae iftMperrrutbfmowhundr dollars SEEA 2WFT. Date Rceei t �`t
($IM)or less.)
I certlfythat inthe per(ormanceofthewmk forwhichthb permit bbsved, WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I shall nm employ any person in any manner co become
as to subject to the
Z
Workers Compensation Laws of California.Date WATERSYSTEM/TREATING PAID
Z Applicant
Z O NOTICETO APPLICANT.If,aNermakmg this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__SQ,FL Date Recei t#
Fshould become subject to the Workers Compensation provisions of the Labor TOTAL:
W Code,you must forthwith comply wahsuch provisions or this permit shall be
W > deemed revoked. BUILDING -E a CO
ap CONSTRUCTION LENDING AGENCY SEISMIC FEE / a
I hereby affimt that there b a construction lending agency forth#perform~ ELECTRIC FEE
Z ante of the work for which this permit Is issued L5m-3097,Cie.C.) TOTAL:
U 2 Landerb Name PLUMBING FEE
1L F Lenders Address QTY. MECHANICAL PERMIT FEE
O W Icertifythmlluvercadthbapplicationand tatethattheabova ln(ormatlmn MECHANICALFEE
d bcorrect.I agree to comply with all city and countyordinanms and tate laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
F- Z city to enter upon the above-mentioned property for inspection purposes. AL7ERORADDTOMECH.
V - (We)agree to save,Indemnify an d keep harmiess the City of Cupertino Date Receipt#
against l-billtios,judgments,"sand expenses whit yin anywayacme AIR HANDLING UNIT CIO Ill"CFM) SUBTOTAL:
agaWts ' In con�uenm of the grant' RVft R`^^�/a/91
•/I]s`/a1',n,,.nl AIR HANDLING I1ATf(OVFJi tO,OW CFM) CONSTRUCTION TAX
Slgnsture of APplcant ontnctor Data IXIIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAI D:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous HEATING UMT(T0100,000 BTU)
maierlalas defined by the Cupertino Municipal Code,Chapter 9.11,and the Date Reeel t#
I and Safety Code Section 25531(a)7 HEATING UNIT(OVER 1 WOOD BTU)
❑Yes M No TOTAL: s
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emitaw
hsrdous air centaminb as defined by the Bay Area Air �Y
.•
Quality Management F1Distflet?No U BOILER-COMP pbE'pR 100,000 BTU)
Y ❑❑No
I have read the haaMcus materials requimments under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) Ala
t the Califmm-HealthA Safety Code,Sect ions 25505,25533 and 15534.1 4�p¢a jBOi
u nd coos rid that if the building does nm mrrently have a terunt,that it is my NEW RESIDENTIAL MECH.
mspowibility to notify the occupant of the requireoents which must be met
prior to issuance of a Certificate of Occupancy. /!j{sa of cu
+as11�� WR8►Nno
Owner or authorized agent pate
70TH L: ISSUED B
OFFICE COPY