22299 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMIT NO.
Bul�n060 �� ��'. Dom. 22299
nets time: ne: A A A
'-F � N 2"b oDy3 CITY OFCUPERTINO-BUILDING DIVISION. _.Z
Contrad9rs Nam/ Lie.No: APPLICATION / PERMIT G
-g b &Zf4 BUB,DING-ELECTRICALPLUNBING-MECHAMCAL CATEGORY CONTROL X
Arc IteR/Enginrer, V
/'"JX Ie. o;
:4
a QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: / — j2j tji,14 (-P ( PERMI'TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am Ecrosed under provisions cf Chapter9(commmc- APPLIANCES-RESIDENTIAL JOB DESC ON
ingwith Sedfon7000)of DiAAon3ofthe Bualnessand Pmfe msCode,and my e] �I �n1 � L��/
license la in full(.testi ddfed. PANELS 0"t;12 V ,� E
Liconu lam LIc.X614 IY b
Date�Contnctor / L QOAM15
AR CHITECPS DECLA TION 20FIODO AMPS
�qqp++�70 I understand my plans shall W used as public records. OVERIODOAMPSEA $/SQ,Fr.
Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSCUTER
L., Ihercby affirm thatIam exemptfrom the Contractor's License Law for the /
7.O... (o1lowln reason.(Section 7031.5,Business and Professions Code:An d or
po Fi4 r moot•whkhwquU apemtittommtmMt ter,impmwdemollah,ormpair TEMP P .MEIERORPOLEINSI'. Ga
� ,,ai-1 anystmdureprlortolbis --ce,LLsorequlrestheapphcntforsuchperMtto
�R E V file a signed statement that he Vcesed bl
linpursuant to the provons of the EWER DEVICES
Oµ Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl-
I., OS sion3.fthe Buni ..dProfessions Code)orthathebemmptthemfromand SWIMMING POOL ELECTRIC VALUATION
S yd the basis for the alleged exemption. Any violation of Section 7MI5 by any '
OPPappUcent fora permit subjects the applicant to a civil penalty of nor more than OUTLETSSWITCHESHXTI3RES Soo
q five hundred dollan($SOD). NEW RESIDENTIAL ELECIT Ff.
^^��q I,as owner of the prop", `SQ STORIES TYPE CONSTRUCTION
I-Q O ruction,willdothwk and t entmcpwre is net intend dor offend for
4 O sale(Sec 7044,Business and Professions Cade:The Contractors License Law
L'j S$ does not apply to an owner of property who Wilds or improves thereon,and SRF .UNITS
0.0. who doessuch work himselforthrough his own employees,provided that such OCC GROIII'
Improvements are not Intended oroffamd forsals.IL however thebuilding or TOTAL:
Improvement bsold withinoneyearofcompletlon,the owner-builderwill have
the rdenof provingtat he did not Wild orimprove for purposeofsale.), QTY. PLUMBING PERMIT FEEp(pp z NE — ApNr
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mtr
muct the pmjed(Sm.7044,Businessand ProfessionsCode:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilda or Improves thereon,and wW mntric s for such ptojects with a
,�+darts)ficensed pursuant to the Commerce.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec. B k P C for thin reason
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
S WORKMAN COMPENSATION DECLARATION RECEPTX
01 hereby affirm that I have a certificate of consent to self-Insure,or a FD(TURES PER TRAP SCHOOL TAX Y N_
certificate of Workers'Compensatlonlmurance ma certified ropythereof(Sec. RECEPT X
GAS EA.SYSTEM-1 INCA OUTLETS
C.
3 PARK FEE Y_ N_
GAS EA.SYSTEM-0VFR 4(EA)�an p, BUILDING DIVISION'FEES
Certified m is to (shed.
- GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertiBed ropy u filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t#
Tlhlssacii.n need not be m
copleted If the permit k!.tone hundred dollars p
($1I0)orfyth WATER BEATER W/VENT/ELECTR ENERGY FEE Y N
Icenot thatoy an petitininan tmanter forwhkbco pesubjecrenn is iso 4; —
1 shall not employ any person in any manner eo u to became subject to the WATER SYSITM/TREATING
workers compere yoytaw.fir Calu/myy.Dat� PAID
O Z NOTICApplicant AN 3 l
Z p Amid
su ICAM:IL orkers'Comh ationktimisonsoftlon,you 'N`bw RESIDENTIAL PCMB. SQFT. Date RTA t#
Coe,you most fort ct wit the ply with
Compematlonprovkiomoftbe Labor TOTAL:
N
Code, forthwith comply wltb each provisions.,this pemdt shallhe
W > domed revoked. BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perform
7OZ "anceof the work for which this permit V Issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
V 1 'dens Name PLUMBING FEE
LL F lander's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W is cI certify that l have read this application and gate that theaboveinfomatlon
ormci.]agrceto comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to Wl[ding construction,and hereby authodu representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR AUDIO MECH.
_ (We)agree to save,Indemnify an d keep harmine the City of Cupertino Date RixeiptM
against Ribillit jadgment;co hand expenses which may In anywayaceme AIR IL&NDLINC UNIT GO IQOOO CFM) SUBTOTAL:
against sea ty In ronaaqu of tl nting of this permit -
_ AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Sigmtureof Appllant/Contractor Date — EXI)AUSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS RIALSDISCIASURE
Will the applicant or future Ing occupant store or handle haysreous HEATINGUNBT(TO100,000RT11)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Reael tN
Heahhand Safty Code Scdi..25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL: T
Yes M No
Wilitheappll-et orforam Wilding—pantuseequipoant.,devi. VWTILATLONFAN(SINCLERESID) ISSUANCE DATE
which emit hatanious air contaminants as defined by the Bay Area Air
Quality Management Dbtnct2 BOILER-COMP(3HP OR 100,IXD BTU) L
Yes No M_I
havereadthet,azardo...tedalsmquimwntsunder Chapter6.95of BOTLER-COMP(OVER I00,000 BTU) N'
the Califmla Health A Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have a tenant,that it
nsiis my NEW RESIDENTIAL MECH. —SQ-17 JUN 2.).
respobBity, mM to notify the occupant of the requirements which must be TJ�
prior to Issuance of a Certificate mOcmpancy.
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY