22768 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
me BuildingProject Identification ,PERMIT NO.
Building Addnae: 22768
"G)AL l7 EV,r lTJS
(�
rrrAL DAT7.
N �} CITY OF CUPERTINO-BUILDING DIVISION
Lie.No: APPLICATION / PERMIT
BUILDINC-ELECTRICAL•PLUMBINFMECtGMCAL CATEGORY CONTROL N
IIIAnchlueffhogincer: Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, PERMITISSUANCE 1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirent.m l am licensed under provisions of Chapter 9(coemene APPLIANCES-RESIDENTIAL JOB DESCRR'TION
ingwlth Sedi.n7000)of DWislon3ofthe Bueineassan//d PPmfenionsC.de,and my
eclat effect PANELS
b2'V Oiala L
DateJ7
Contractor
ARCHITECTS DECLARATION 201-1000AMPS
M OO I understand my plane shall be used As public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.PT.
Iy(� Licensed Professional SIGNS ELECTRICAL E D IN
<LG�i OWNERex NLDBR DECLARATION M P U T E
!n`] SPFLULCIliCNT/M
zt• IherebyalRrtnthallam exemptfromthe Cont ractofe Llcens Law for the
QQ Oppppp lollowingreason.(5eoOm7Q3L5,Basin.and Profession.Code:Any city or
r-4 county which requires a permit to construct,alter,improve,demolish,or repair TFMP.METIX OR LE INST.
mystructure prlorto its isauance,aisorequlres the applicant forsuch perndtto POWER DEVIS. l !6
.. file a signed statement that he is licensed pursuant to the provisimu of the
3uO.G Contractor',Lkenee Law(Chapter9(comnrtncing with Section 7000).f Divi- SIMMI POOLELECTRIC ��
alon 3 of the B.Air.and Prokmb.Code).,that he is exempt therefmmand VALUATION
O 5 the basis for the'alleged exemption. Any violation of Section 70315 by any OUTL SWITCf IFSFIXTURES
applicant(ora permit subjects the applicant to a civil penalty of me more than
Bv61,asundnd owner of (epm RGSIDENIIAL ELECTR SQ.FI. STORIES TYPE CONSTRUCTION
6 I,as owner.(rise property,or he employees with wags as their sole
cone
=.ib.,we.=..work and ions Code:Th not Intended or offered for
❑ ale(Sec,7014 Busine...d Profeslom Code:The Cantactol.Ucerue Law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC,GROUP RFS UNITS
who doce..ch work himself or through Meown employees,provided that such
Improvements are not Intended oroflered foreale.If,however,thebuilding or TOTAL:
i provement issold within.neyearofcompletion,theowner-bullderwlll have
thebodenof prowingthat he did na build or improve fm purpose of hied. QTY, PLUMBING PERMIT E FLOOD ZONE APN
Lf L as owner of the property,am exclusively mntreniog with licensed
centraRon to construct the projact(See.7014 Business and Profesi.m Code: PERMITISSUANCE
The Contncter's Licerue Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EN
Wilds or Improves • -
thereon,and who contracts for such p(ojects with a FEE SUMMARY
co nor(s)Ilcensd pursuant to the Contractors License Law. BAIX PIAWI'ROTECT.DEVICE
Lf I am exempt under Set B&P C for this reason
Owner Data DRAINS FLOOR ROOA,AREA,COND SANITARY Y_ N
RECEPT N
r–t WOREALA COMPENSATION DECLARATION pIXIl1RES PER TRM SCI{ODL TA% Y_ N
uI hereby affirm that 1 have a certl0ate of consent to self-Insure,or a RECEIPT
certificate ofWorken'Compereatlon Insurance or a certified ropy thereof(Sec.
3800,Lab C.) S EA.GASYSTEM-1 INCA OfTIL 5 PARK FEE Y N
Policy If
f RECEIPTT N
oC �Any GAS FA.SYSTEM-OVER d( B UI L DING DIV
ISION FF.ES
CelRed copy is hereby furnished.
CrtrtlRed copy is filed with the city Impaction division. GREASE/INDUSTRL WAyfi INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAI' PAID
COMPENSATION INSURANCE SEWER-SANITAR IORM EA.2110F1'. Date " RcC t t#
(This section need not W completed if the permit is for one hundred dollars
($10(O ,les.) WATERIIE3 W/VENT./ELECIR ENERGY FEE Y N
I certify that in the performance of the work forwhlch this permit is lsvN, —
I shall no employ any person In any manner so As to became abject to the /.IREA.DhG
Workers'Compemation laws of California.Date WATT PAID
licant __
Z Z NOTICE TO APPLICANT.If,Aker making t his Certificate of Exemption,you NEV/ESIDENTIAL PLMB._SQ.FT. Date RCtel t#
F2 should became subject to the Workers'C^mpemallon provisions of the Labor TOTAL:
CC _N Code,you most fort lovith comply with such provisions or this permit shall be
W y dMmed revoked. QUILDING
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaf0rmthat there isa mvtraction lending agency for the perform- ELECTRIC FEE
M Z anmofthew.rkf.rwhichthispermitls Wued(Sec.3097,CIv.C.) TOTAL:
V O lender's Name - PLUMBING FEE
LL ~ Lender's Address Q'r3'. MECHANICAL PERMIT FEE MECHANICAL FEE
OW leerifythatl havereadthisappliailonand statethattheabovelnfomstlon
1 iscoreact.icgree to comply with all city and county ordinances and state laws PERMIT ISSUANCE EES PAID:
>. W relatingto Wilding construction,and herebyauthorim representativaofthis
I– Z city to enter upon the above,mentiunsd property lar inspection purposes. ALTERORADDTOMECH. Date RCCCI t#
_ (We)agree to save,Ind comity an d keep harmless the City of Cu ped Ino
against liabilities,Iidgmenb,costo and expenses which may In any waymcru. AIR HANDLING UNIT(TO I g000 CFM) SUBTOTAL:
said C con ens of the granting of i s permit.
AIR HANDLING UNIT(OVER 10,0q CFM) CONSTRUCTION TAX
Signature° Appli / -1 – Dater-7 CONSTRUCTION TAX PAID:
HA7A RDOU M ERIALSDISCLOSURE
Wllltheapplimatorfulumbu Ing occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) // Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I{ealth and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
QYcs No
Will the applicant or win Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit W vrdous air contarromets as dented by the Bay Area Air
ji Illy Management District? BOILER-COMPOHPOR100,0(DRTU) ['f A
n No i 6
havemadthehaza ohs maierlais requirements P under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1 Jq�y oY
understand that iftherally th.mup.rt.oco recntlyhavea tenant,that b met NEW RESIDENTIAL hfECJi. SQ.f•T. H 1(In2
unpostand that
notifythe occupant ofthercntlyhve which at it m s9s7
prior to Issuance of a CertiOate of Occupancy. CITY�r
Owner or authorized agent Date $SUED BY:V
TOTAL:
OFFICE COPY