22419 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect ldentificaHo PERMIT NO.
�l
Bull
ul mg/sdTdr5f*ce�8133 /L%l3 L).woLF 1& 22419
race aame: sone: �- p p
L �U IZ N G CITY OF CUPERTINO-BUILDING DIVISION
cmnraemraName: Lie.R. APPLICATION I PERMIT `� C r
• S GLI C•9S• G BUILDINGELECTWCALPLUMBING-MECHANICAL CATEGORY CONTROL
n
Architect/Engiee Lic.No:
QTY ELECTRICPERMIT FEE
AA BUILDING PERMIT INFO
Addenuo PERMITISSUANCE �VU 171 ❑ ❑
LICENSED CONTRACTOR'S under provisions
�LI
Ihereby
Socio 70thatlam BcmsedunderpossanvofChapter9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingweh infell700Wof effeon3ofthe Buslnmand ProtmionsC,pde,and my PANELS
IA151�LL •�rCyNS SaJ�J
license Is In alis(y y�d-#
Licenser C:• LIeN_ I � S
Date 7-9-4/ CHInctor 201-1000A.MPS
UP TO 2DO AhM
ARCHITE a uwd E ubilc rdi'l OVER I ODO AMPS SQ.Fr.FLOOR AREA $/SQ.FL
Ob
�7I understand my phv shag be used as public relents.
(� Licensed Prefea Tonal SIGNSELEC7RICAL �� LED I N
4 OWNER-BUILDER DECLARATION 1
1n] SPECIAL CIRCUIT/MISC
1. ,7a following reason,
iectlam exemptfromthed Professions
Llrense law fort he C�QI3 It n n
F2Hfollowingreason.irectioermi1.5,Buslnenand Professions Code:Any cityor TEMP, OR POLE INSI', �1J�J I 'l1iJq
� my which requimapertNOo construct,ager,Improve,demnlbh,orrepalr
q anTER
ystrucure prior to it.announce,at..requires the applicant frrsuch permit to (OWER DEVICES �J//]'� �Q
EEp� Rlc a signed statement that he an licensed pursuant to the proWloro of the [ G•41 `V
03°'G Coatnctor'sLicense Law(Chapter9(commencing with Section 7000)of Owl. SW)MMINGIOOLELECIIC VALUATION.
LOS slon3ofthe Businmand Profmlov CWe)orthehebemmpttherefmmand
the basisfor the allegedexemption. Any violation of Section 70315 by any �O / Q
O applicant fora permit subjecestheapplicantloa civil pevhet yofnmore Hun OUTLETS-SWITCHES-FIXTURES (/
five hundred dollars(SM.
NEW RESIDENTIAL ELECTR—SQ-FT. STORIES TYPECONSTRUCTION
❑I,as owner of the property,ler my employees with wages r their dole
5NQ compensation,Busio the ness
and kand the s Code:The
Coot ntractor orcensoffered Law
p salesnot.apply
to alnow and Professions Cede:The or
paves thereon Lid
�j 5 docs not apply to an owner of property who builds or improves thereon,and OCC.CROUP HIS.UNITS
who doessuch work hlmselmrthrough his own employees,provided that such
Improvements are not intended orofferedfor sale.Iflorweemr,thebuildlegor TOTAL: /)o
Improvement issold within oneyearofcompletlon,the owner-bullderwlll have
try,�Iden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
IJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construe the project(See 70K Business and Profmbrs Code:
71.Contractor's Lt..Law does one apply to an owner of property who
Wilds or Improve(haeme,and who command for such Ino)ects with a TER-DRAW k VENT-WATER(EA)
ociHEactor(s)licensed pursuant to the Contractors License Law. wCK P TELT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
DRAT pAREA,GOND. SANITARY Y_ N
Owner Date ftECEI'IN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N_
n1 hereby affirm that I have a evrtlRatc of consent to self-Insure,or RECEIPT N
certificate of Workeon'Compeasation Insurance or a certified copy thereof IS". GAS EA. TEM-I INCAOI7fLEf5 PARK ITE Y_ N_
3BOO.Iab,C�Com.P a�• s RECEIPT N
Pollry p W G _
BURRING DIVISION FF.ES
CcrtlBeaco bhercby fumished. GR /INDUSTRLWASTEINTERCEPTOR PLANCHECKFEE
certmed copy in mea wile the sty wpectmn aroimme.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Recei t#
(This section need net W completed lithe permit Infer one hundred dollars
(stm)orleat.) WATER FEtFn7TRw/vFNr/F3 rr1.R ENERGY FEE Y_ N_
I evenly that In the performance of thework torwhich this permit Is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workeoi Compensation laws mf California.Date
OZ Applicant NEW RESIDENTIAL PLMB. SOFT. Date RCCCI t(i
Z O NOTICE TO APPLICANT:ILader ran king this Certificate of Exemption,you
N should become subject to the Worlon'Compensation provisions of the Labor TOTAL:
� � Code,you muse forthwith comply with such provaslmm or this permit shall be U N FEE •PA
deemed revoked.
IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a E3 I herebyafRmothat there Is a construction lending agency for the perform- ELECTRIC FEE .0
M Z and of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
0 O Lcadcr's Name PLUMBING FEE
LL F• lsnder's Add mdd QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
lttdifythatfhavercadthbappliatbnandnatethattheabove Information
O 111
a Is correct.I agree to comply with all City and county ordinar=setd slate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives of thin
city to enter u Pon the above-mentions property for Inspection pit rposn. ALTER OR ADDTO MECH.
f. Z d kDa[C ReeCiplN
V — (We)agree to save,Indemnify an keep harmless the City of Cu pert Ino AIR HA UNIT(7010,000 CFM)agalvtlUbllities,ptdgments,mets and ex enseswhlch may In anyway accrue SUBTOTAL:
agal I yin a.g enev ofthe ting of this permit.
��T1( • AIRHANDWNGUMT(OVERIO,OWCFM) CONSTRUCTION TAX
^•A't' CONSTRUCTION TAX PAID:
Signature of Apphant Contractor le Date IXHAUSTHOOD(W/DUCT)
HAZARDOUSMATERIALADISCLOSURE
Will the applicant or future budding occupant store or handle hazardous HEATING UNIT(TO IM."BTIU Date Recei to
material as def ned by the Cupertino Municipal Code,Chapter 9.IZ and the
Iialth and SafetyCone(�.nectio 2553Z(a)7 HEATING UNIT(OVER 100,00)B"Cl0 TOTAL: .2C
F1 Yes "• VENTILATION FAN(SINGLE REND) ISSUANCE DATE
Will the applicant or future n building occupant use equipment or devices
t wlrkheManagem nt airrict? ntsv de0ned by the Bay Area Air
Quality Management District? BOILER-COMP pFm OR 100,0(0 BTU)
4Yes lrTlr�aa..�������� s-a
havcrcadthehara ousmaterialsregWrcrrcntsunderChapter6.95of BOILER-COMP(OVm 100,00007V) JUL
the Calltornia lealth k Safety Code,Sections 25505,25533 and 25536. 1 V4 F le
understand that ifthebulldingdoes not corremly have a tenant,that ltkmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be mel NN�1y
priories raceotaCertfdato.(Oc airy. — _q Wy d.CUMURn
Owner or authorized agent Date/ ISSUED BY�o_'(rVl����
TOTAL:
OFFICE COPY,