22087 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project Identification PERMIT NO.
Building Address: 22087
q, s
nerd ams: one: App A A A
y �5 7 CITY OF CUPERTINO-BUILDING DIVISION
ontrador's a Lic.No,. 1 APPLICATION / PERMIT ��2q 9•'
C ) D BUILDINGELECIRICALPLUMBING-MEC}1AMCAL CATEGORY CONTROL#
A hl` /Engi Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSEDthatI.ONTRA TOR'Sule,pr DECLARATION q I
Ihereby affirm that lam Lcenaed underprovhlons of Chapter9(rommenc FLIM' E JOB DESCRIPTION
ingwith Section7000)of Divism3ofthe Buslnessand ProfesnonsCa and my
limns hlfull fora andeffect. ANELS, ® � 1;� ��1��
LicenseClass Lkec r VJ'
Date Contactor
ARCHITECPS DECLARATION 201- AMPS
ne 070 I understand my place shall be used as public records
O SQ.FT.FLOOR AREA E/SQ.FT.
a0 Licensed Prolesslonal 9GN5 ELECTRICAL �_q-L
6^� OWNER-BUILDER DECLARATION
IherebyaSPECIALCIRCUIT/M1SC
71.., 7 fRmn that Is.exempt from the CoarseEm's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE)NST.
VVV
ppc� cauntywhichrequi apemtittomnstruct,alter,impmve,dennlbh,orrepalr
gg4S.s anystnume,prior to its beenance,also requlrestheappliant for such permit to POWER DEVICES IN O
Rlfit, b a signed statement that he licensed pursuant to the provisions of the
ln Contractor's License Law(Chapter 9(commencing with Section 7000)ofOwl- SWIMMING POOL ELECTRIC
O slon3 ofthe Business and ProfesilonsCode orthat he h exempt therefromand TfON
<5 the Exists for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWI7CIIF_SFXTURES
eppllane(oraperMtaubjeRathe applkanttoadvll penalty of not nnrcthan a �� lC30
five hundred dollar he pr. NEW RESIDENTIAL ELECTR
3 ❑ as owner of the property,or my employees with wags as thele sole �• SOWS TY E CONS RUCTION
Q,
compensation,&c.70K
ldess and rk,Pr and thes Code:rehnat Intended orofferedLaw
O
sdoes ale&c.apply
to Business owner
fpropertIe who
Wilds Contractor'stherem law
j$$ whorl tapplytoanowner ofproughhisonemorimpmovided that
whodcessuch workhimxl(orthrwgh hisownemployeee,provided that such ^ OCC.GROUT' RFS.UNITS
Improvements are not Intended oroflered for sale.IL however,thebuilding rer TOTAL: 4dD
Improvement Is sold within oneyearofcomplefion,the owner-builder will have
I denofpmvinglhathecild not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTAODPDNE APN
as owneCode: ppIT ISSUANCE of the property,am exclusively contracting
Awith licensed
Ataoa to Zctoo uct the project(Sec.70K Business and Professions Code: ^L,•
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Impmm thereon, and who contracts for such pLujeds with a
cq[Ltjactor(s)hod sed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FLL5
Owner Date DRAINS FLOORROOF,AREA,COND. SANITARY RFC N
WORKMAN COMPENSATION DECLARATION T at
MTURpS PER TRAP ,Co -SCHOOL TAX Y N
❑i hereby affirm that I have a eartifiate of consent to self-insure,or a
certi0ate of Workers Compensation Ire urance or a certified copy thereof(Sec. EI
f(SRECPT'#
3800,Lab C.) IS GAEA.SYSTEM-11NC.40UTLEI5 Cam PARK FEE Y N
Policy# RECEIPT#
Cam ny GAS EA.SYSTEM-OVER 4EEA) BUILDING DIVISION FFF5
IT
copy h hereby fumhhd.
[:]Certifid copy is filed with the city bopection division, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID Lgsil
COMPENSATION INSURANCE Lk:: L �� f�
(Thhsction need not becompleted if the permit tsforom hundred dollars SEWER-SANITARY-STORM EA.ZOOFT, �Rld/Loto RCCCi # ��a�
(5100)or Ievl
I cenlfy that In the performance of thework forwhich this permit is laud, WATER HEATER W/VENT/El TR L ENERGY FEE Y_ N
I shall not employ any proem in any manner so m to become subject to the
Workers'Compeceatlon laws of California.Date WATTRSYSTEM/TREATING PAID
O Z Applicant
Z O NOTICE TO APPLICANT:R,aker making this Certlfiate of Exemption,you NEW RESIDENTIAL PLMB. SQPT. Date ReCpl t
Nshould become.ubject to the Workers'Compc.,In pmvhbce of the Labor
N Code,you must fo hwith comply with such proWlons orthh permitshall be
W
p> aeed revbkedN. 6UILDING FEE TOTAL.
d CO
mRUCTION LENDING AGENCY SEISMIC FEE s
Z
I hereby affirm that there It.mcetruction lendingagencym fortheperforELECTRIC FEE 1(7-j) Q.
ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
0 O finder'sName y PLUMBING FEE
ly H nder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iartitythatl have read this application and na[ethat lheabove information L
1 hcorrect.lagreetocomplywithalldtyandwuntyodinancesand state laws PERMTTISSUANCE FEES PAID:
} W relating to building construction,and herebyauthorlcrcpresntatwesofthis
I— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH.
_ Me)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
agobutl illties,pdgments,cons and nsawhlchmaylnanywayaccrve AIR HANDLING UNIT ITO 10,0D0 CFM)
agai s dCity lncon uenc ft a ting of this permit. SUBTOTAL:
_ AIR HANDLING IIMT(OVER 10,"CFM) CONSTRUCTION TAX
Signa Teo Appllca t entracte Date EXHAUST HOOD(W/DACE CONSTRUCTION TAX PAID:
H ARDOUS 1 FRIA SDI CLOSURE
Eltheappllca or(uturebuitd ngoav an toreorhandlehaadous C HEATING UNIT(T0100,000 BTU)
material.actr dbytheCupertinoMunicipa odrChxptcr9.IZasdthc Date Recei t# _
Ite�ait Y�d Safety Cadr,Se Jioon 75532(a)7 HEATING UNIT(OVER 1OQ000 BTU) TOTAL
Will the applicant or fumrebuilding occupant meequipment or dcvicos VGN77LATION FAN"IN;RBIDI I�d NCE DATE
which emit harurdous air ronmminants as ciefimd by the Bay Area Air
Quality Management District? BOILER-COMP OEfP OR IntQQQ7 Yea �No IY 8 gAVj
have read the haze ours ma(erlals requlrcmenro underChapter6.95 of BOILER-COMP(OVFR 10JU5the Califrnia Health&Safety Code,Sections 25505,25533 and 25534. 1understand that ifthe buildingdces not currently haveatenanL that ithmy NEW RESIDENTIAL ME Cai1A
responsibility to notify the occupant of the requirements which must be and J11
prior to Issuance of a Certificate of Occupancy.
Owneroraothorimd agent DateO, _
TOTAL: ISSUED I
OFFICE COPY