22342 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Protect Identification
PERMIT NO.
Building Add.,: T3 60111 G/, - 22342 234Z
wnera ams: ��JJ one: A �T
SNE gC HIL) CITY OF CUPERTINO-BUILDING DIVISION
enatr, o ams: QQRL/ 1 f��yg: APPLICATION / PERMITer b l I
l J BUILDINGELECnUCA4T-UMBINGMECHANICAL CATFLORY CONTROL N
Architect/Tragi LM.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..: PERMITISSUANCE ❑ I PLUME
❑ ❑
LICEiNS ED CONTRACTOR'S DECLARATION
I hereby ffi.that l am Bcensed under provisions o(Chapter9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwilh Section 7000o(D1vid°n3ofthe Busineesand PmfessimsCode,and my
lienee le infuH o rad affect, kJs PANELS
la
Lkense Lk.N
Date Contractor
ARCHITECT'S DEC ATION - 201-1000 AMPS
Qz l understand my plass shall be used as public reurclL OVERIOOOAMPS SQF-r.FLOOR A $/SQ.FT.
Iy(/ Llansed Professional SIGNS ELECTRICAL E
z TE
�6�a OWNER-BUILDER DECLARATION SPFGIALCB(CUIT/MIhC
71.,�'�j�' [hercbya(Brm'hat lam exempt from the Contractor'sLlanm Law for the
qqqq ::::�JVM L
following mason.(Section 70315,Business and Professions Code:Any city or
LR
countywhichmqubesapermittoasstmctalter,impmve,demollah,ormpalr TEMP. OR OLE INSf.
°� anystmc repriort°IfeL ancealeorcquimtheapplimntfasuchpea tto
O file a signed statement that he is licensed pursuant to the provisions of the ]TOWER DEVICES '
30G Contractorm
Contractor's License Law with Section 7000of Divi- SWIMMING POOL ELECTRIC
t, slon3ofthe Buslneasand Pmfemlom Code)orthathelsexemptthemfmmand VALUATION
the balls for the alleged exemption. Any violation of Section 7011.5 by any
I� Qct
applicant fora permit subjects theapp8cant toe civil penalty of not mom than OUTLETSSWITCHFSFIXIURES
ted' fiv�e,huns ed owns ofthears pro NEW RESIDENTIAL ELECTR SQFf. STORIES TYPECONSTRUCTION
cumpensation,will d o the work,and the LJ I,as owner of the property,or my employees Is no Intended with wages r offered for
thele dale
5,00 sale(Sec.apply
to
o anowa.andf property Code:The or Improves
License law
doe$ who not ducepply torn ownerofpro11 ugh hisobuilds nemorimproovidedthat
suh OCC.GROUP RFS.UMTS
onprowsemi...such rkMmeended orughhbownemp,horwa,ar,the
uildinuch
Improvement ftsold ithindedoroofcomffered orefor,tis howevegffider ill have TOTAL:
Improvement atsold wlthinoneycamfcompletioMlhn ownervbullderwill have '
t"Men of proving that he did cwt build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE pLOOp2pNE ppN
u 4 ad owner of the property,am exclusively--d-,with Ilanadd pQ1MRlSS[IpNCE
contractors to anstma the project(Sec.7644,Business and Pro(essions Cade:
The Contractor's License law does na apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptuiects with a
c ctortFEE SUMMARY
Oafs)licensed pursuant to the Contractor's License Law. BACX FLOW PROTECT.DEVICE
LJ!am exempt under See' B k P C for that reason
Date
Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RWEIT'r X
WORKMAN I haw a JSATION DECLARATION EBXIURES PER TRAP SCI400L TAX Y N
I hereby affirm that T hdvo d certificate of consent to.pytheure,or . RECEIPT Y
38M�diLl teof Wor9en'Compe`/r ru�y�aatTi°,nlrouranaaaartified ropytherrnf(Sec. GAS EA SYSTEM-1 INC4OTILES
3800,Lab C° Tia/ PARR FEE DING DIN
Peliry N GAS EA.SYSfT]d-0VER 4(EA)
Com v BUILDING DIVISION FEES
OCertlfled cop with
the city CREASE/INDUgML WASTE INTERCEPTOR PLANCHECK FEE
�CertVed copy ls filed wltM1 the city inspection division.
CERTIFICATE OF I6(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
ffSEWER-SANTEARY-STORM EA 200Fr Date Rami tit
Ms season need et nM completed If the pemdt at for cam Fundred dollars
(StOo) fytha WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
that in anyperson In
tmannerfo""to
co Parrott1.Rothesued, —
I shall not employ any person In any mannerso m to became abjM to the
WorCompensation laws Of California Date WATER SYSTEM/TREATING PAID
0 Z Applicant NEW RE9DENTIAL PLMe. SQFf. Date Remi tN
Z O NOTICE TO APPLICANT:If,after=it]ag l his Certiluat,of Exemption,you
Fshould become subjectto the Worker'Compensation provisions of the Labor TOTAL:
N Code,you=at fort hwlth comply with such provisions or this permit shall be U
> deemed revoked.
a C CONSTR UCTION LEN DING AGENCY SEISMIC FEE
IL12ING FEE
I hereby affirm that there is a construction lend ing agency the perform- - 70TAG ELECTRIC FEE
( Q ance of work for which this permit at Issued&c.3097,CIv.C.) PLUMBING FEE
,) Larder's Namc
IL F Lcndera Addmas QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W (certify that l have read thlsappllcationand Ratethattheabove-`0 it.
n
1 lsarrect.lagmlo comply with allcttyand county or PERMRLSSUANCE 1�� FEE$PAID:
} relating to building mmttualon,aM hereby authodre mpmcatativa ofthls
Z city to enter upon the above-mentioned property,for Inspection purposes. ALTERORADDTOMFCH.
— (We)agac to mni(y and keep harmless the City of Cupertino Dale R6Cei td
agalmtllab11lt1 ,pdgme e,audtsand ex mwhichmayma wayacrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
siFt taaid ty equence o(the rating this
pertnd.
�7 AIRI4ANDLINGUNITIOV010,000C17M) CONSTRUCTION TAX
Signature Ppifca moor ore ExRAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
Fa- DISCLOS RE
Wflitheappl orfuture building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU)
nDate Recei t#
utetial as dented by the Cupertino Municipal Cade,Chapter 9.12,and the -
Health and Safety C°der�Sectlon25532(a)7 / HEATING UNIT(OVER 100,000 BTUI
my. L_I No TOTAL:
Willtheappifcant orfuWmWildingoccvpantuseequlpmentordevlas VENTILATION PAN(SINGLE RESIO) ISSUANDATE
which emit har rdous air contaminants as defined bythe Bay Area Air �
tlu
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) ����11
4 Yea Q.N.o n1
have read the Fav materials requirements under Chapter 6.95 of BOILER-COMP(OVER 16g000 BTU)
the California Health k Safety Code,Sections 25565,25533 and 25534.1 �4N (�
understand that(fl Ilding does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
mpom16111tyt atl heOccupant of the
requirements =at be met
prlortoissu ceo he cctcaofnt pan �`a 'WTI_ 11Y4Nrr1
G a� 8
Owaerorauthorla
D TOTAL: ISSIRiD BY.- �L
OFFICE COPY