22089 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:. 22089�'�
nes one: -
w,(.r CITY OF CUPERTINO-BUILDING DIVISION
C der'sN Uf
Lic.No: APPLICATION'/PERMIT
��v BLDINGELECTWCALPLI)T/BINGMWCH MCAL CATEGORY' CONTROL
Architect/Engineer. �' LIc.No:
tQTYI , � ' ELECTRIC PERiv1.ITr it I' „��FEC� 'BUILDING PERMIT INFO" ,
Addrme:�' ..��M(/ PERMITISSUANCE IZ 0O. INY��,tIlyl
LICENSED CONTRACTOR'S DECLARATION a - �-{-!
I hereby afflrmthat l am licensed under provisions of Chapter9(commoso. APPLfANCLSRESIDENTIAL JOB DFSCRIPRON
Inti Sedion7000IolDlvbion3ofthe BuslmaanPmfeaionaCOdgand my
license Is In full and died, PANELS
,.Cl.
Date Contractor 701-1000 AMPS
�( a3
ARCHITECPS DECLARATIO
px COC l understand my plain shall be used as public remrda OVER IOBO AMPS p /� ® 5/SQ.FT.
g; () Licensed Pmfealonal SIGNS ELECTRICAL / '\/I U T.
GGti LLLL*T7�1 OWNER-BUILDER DECLARATION -SPECIAL CIRCUIT/MLSC /.St a Y R
t, (hereby a(Orm that am exempt from the Contranor's License law fm the E G Y y
F0 - following reason.(Section 7Bf1.5,Business and Israleabns Code:Any city or TEMP.METER OR POLE INST. - Jl
s' cauntywhichrcqulreaapemttommtruct,alter,impmve,demolish,ormpalr
'� anystruc mprlortoltsswincgaleorequlreatheapphmntfonuchperMtto POWER DEVICES
ruG Rle a signed statement that he is licensed Pursuant to the provlslons of the '
3µ Contractor.License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING POOL ELECTRIC " ' . VALUATION
O� Mon 3 ofthe Business and Professions Code)orthat he h exempt therefromantl
< the basis for the alleged exemption. Any violation of Section 7011.5 by any /0 0UTLETS�SWITCHFSHXTURES.
applicant m
fora permit subjects the.pphcaru to a civil penalty of nafore than
five hundred dollar($5010. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole _
7¢ compensation,will do the work,and the structure is not intended or offered for
❑ sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improve thereon,and
s�^ who does such work himself or through his own employees,provided that such !_ OCC.GROUP RIS.UNITS
improvements arcnot intended muttered for sale.l(howevegthebuildingor TOTAL: Qj
Improvement lsaoldwlthlnoneyearofcompleioMthe owner-bullderwlll have
t"rden of proving that he did not build or improve for purpose ofule.). ' ,',';}1 �IPLU111B[IVG;PERMI .,�til 'h.'FEE i .
u I,as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to combust the project (R4, \ PERMIT ISSUANCE
(See? Business an owner
Pf pro ons Code: ' 4 co
The Contractor.License Law aces not apply to an owner of Property who
Wilds or Improves thereon,and who contra's forice such p(ojeds with a ALTER-DRAIN& -WA ) 1
aciottexempt under SoctotheCantrctor'sLicense Law. ..('• "FOUSUEFEES j
ryp(f .
LJ I am exempt under Sec B&P C for this remora � BACK FLOW PROTECT �' ' ' ' " . :FEES
DRAINS FLOOR yA COND., SANITARY Y 'N_
Owner Date ,RECEIPT If
WORK MAN COMPENSATION DECLARATION SCI100L TA% Y N-
❑1 hereby affirmmiters that I have o certificate
ranc of consent to copy
or FIXTURES- �O`' RECEIPT If
3g00certiticate fab CJWorkery Compensation lrsurance ma certifkd ropy themof]Sec. GAS F.A.SY - .40UTLETS ' '�.� PARK FEE Y N—
Policy
- _ RECEIPP N
CffC GAS-EA,SY ER 4IRA)
Com any . - BUILDING DI VISION FEES
Certified copy Is heed with the
city - GREASE/IN LWASIEMTERCEPTOR PLANCI-JECKFEE
Certified mpy,Ls(lied with the dty Inspection division. r
CERTIFICATE O F EXEMPTION FROM WOR KERS' GREASE7RAP PAID
COMPENSATIONINSURANCE SEWER-SAMTARY-STORM EA.]((OFT. Dere Receipt O
(Thisuctian cednotthecompletetif theperrmtisforonehundreddollam P It
($100)or lea,) WATER HEATER W/VENT/ELECTR ENERGYFEE Y .N
I certifythat in the performance ofthe work for.1mht permit is Wued, '
I shall not employ any person In any manner an m 1 me jM to the WATERSYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID
C• Z NOTApplECEt NEW RESIDENTIAL PLMB.' SQT I. Date ReCel tit r
Z O NOTICE TO APPLICANT.If,after making thh Certl(Imte ofExemption you
should become sub}ct to the Worker'Compensation provisions of the Labor TOTAL:'
N Code,you most forthwith comply with such provislons or this permit shall tie BUILDING 'Co
deemed revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d' Ihereby of rmthatthem is a construction lending agency for the perform- TOTAL: Cp ELECTRIC FEE 1st
Z 'ance of the work for which this Fermat is Issued&c.3097,Civ.C.)
O O Lenders Name �_�• - - t. . d PLUMBING FEE' - a
LLE- Lender's Address - QTY::-I MECHANICAL'PERIVIIT„I ',x {;PEEr_. MECHANICAL PEE '
O W Imnilythatl have read this application and statethattheabove mlornution
M Incorrect.Iagmelocnmplywith all dtyand ammyordlnancesand statelaws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hercbyauthoricmpresentativesofthls -
F city to enter upon theabove,menttoned property for WpecHan purposes. ALTER OR ADD TO MECH.
? (We)agree to uve,Indemnl an d keep harmless the City of Cupertino ---Fate ReCCiptM
V agaWtllabiliti cat rtaand expenseswhkhmayl nywa accrue AIR HANDLING UNIT(TO 10,0)0CFM) SUBTOTAL
aX,inst uld Ci re ofthe granting of this pc t
• d ,vR I-uNDUNc unrr(ovER IB,OBocFM) - CONSTRUCTION TAX
of Applicaru/Contractor Daze EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAliA RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant afore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei [N
I/ materialasdefined by the Cupertino Municipal Code,Chapter 9.17,and the
I kalth and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYes No
ill the applicant or tum building ocxvpast use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air cont.rutoo b as defined by the Bay Area Air ,
Quality Management District? BORER-COMPOHPOR 100,0(0 BTU)
F1 Yes ❑No
Thave mad the hazardous maleriab mqulrcrrcnts under Chapter 6.93 of BORER-CONP(OVIR 100,000 BTU)
the California Health k SafetyCode,Sections 75505,25533 and 75534.I
understand that lithe build sg does not rumenllyheve atenant,that it ismy NEW RESIDENTIAL MECH. SQ.IT ��� 3 �� �
rmpomlbilltyro dyt occupant of the rcqulrcmenta whic the and U
prior to es of nificatcofoccupanq. p p�y”
or auihorlud agent y 3`'Gone 1ffiUEISB .- �i r `—
.TOTAL:
OFFICE COPY