22735 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:o L 22735
Loan �CA-
` nere ame: one: A A A Ih
IA UL 4 (3,1 Qt L(— a'53-103 CITY OF CUPERTINO-BUILDING DIVISION �^
Contractor'sT N-Zame: _ rL-Ie.No: APPLICATION / PERMIT
I�1fos f IWI . BUILDINGELECTRICAIPLUMBING-MECFiAMCAL CATEGORY CONTROL#
Architect/Engineer. V Lk.No: . _
QTY ELECTRIC PERMIT FEE . BUILDING PERMIT INFO
Address PERMIT ISSUANCE
LICENSED CONTRACTOR DECLARATION - '
❑ ❑DESC S4ON
Elhereaffirm
that l licensed provisions of Chapter c APPLIANCES-RESIDENTIAL
lwith Section of Division
iv on3ofth.Busincessand Pro(esionsCade,and my JOB
ice.bin full force and effect. PANELS
LicensoCla �_y]CS_Lic.e
#
Date cid_{ _ContraciorUP TO 200 AMPS
��r 11
ARCHITECTS DECLARATION 701-I0DOAMES
9O Z I understand my plans shall be used as public records OVFR I OD0 AMPS SQ.Fr.FLOOR AREA
Z° SIGNSELECTRICAL LED !
Licensed Professional
Q w OWNER-BUILDER DECLARATION
In eEd SPECIAL
CI(CUIT/MISC
zi„ Iherebyaflrm that I am ER the Contractor'sLicense Law for the
following reason.(Section 70315,Business and Pmfessloro Code:Any dry or
PV
FRt'u� ccuntywhich requires a permlttomrswct,alter,improve,demolish,orrepair TEMP.METER OR POLE INSf.
�M�' anystmtt mpeormltslssuancealwrequlrestheappbnntforsuchper tto FEWER DEVICES
file a signed statement that he is licensed pursuant to the provblons of the r
3 w G Contractor's License low(Chapter 9(romancing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUAT O
sion 3 of the Businessand Professions Code)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETS-SWITCHES
<a applicant for a permit subjects the applicant to a civil perultyro
ofna rrethan
nu.p O five hundred delta.($500).
I,asowner of the property,or employees with wages as their sole NEW RES[DFM7AL ELEC7R SQ.FT. STORIES TYPECOOMUCTION
Q Sn ❑ P ork,a my B
d for
,Va compensation,Biai'.O.the work.aesomoCde:Thrnd thestructuam is Cmersenrdorcense Lw
O sale(Sec.apply
to ainow and f property Code:The or imprrwt Lkense law
5 S does not apply to an owner of property who n lids or Improves thereon,edthat and OCC GROUP RFS.UMTS
who doesauchwork M1lmseif orthrough hisownemplgees,provided that such
improvements are not intended oroffered foreale.If,however,the building or TOTAL:
improvement issoid withlnoneyearo(completion,theowner-builderwill have
thur, Lden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD PINE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who ALTER-0RAIN&MFM-WATER(EAI
Wilds or Improves thereon,and who contracts for such pipjeab with a FEE SUMMARY
�q¢Ifador(s)licensed pursuant to the Contractor's License Law. BACK FLOWI'ROTECT.DEVICE
1fal am exempt under Sec. B k P C for this reason
Q.�TSI DE FEES
Owner Date DRAINS FLOOR ROOF,ARF!,COND. SANITARY Y N
RECEIVE#
WORR]NAN COMPENSATION DECLARATION a� M
V FIXTURES PER TRAP 0.9.!! SCHOOL TAX Y N
❑I hereby affirm that f have a certificate of consent to sell-insure,ora RFGEI'f N
certificate of Workers'Compereation lnu men or a certified copy theomf(Sec. GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y_ N_
3800,lab CJ �p��n�S� ^ RECEIPT i'o14y# O V GAS FA.SYSTEM-OVER4(EA)
Com anv ST{�T—fa r^ / BUILDING DIVISION FEES
Cb
copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certfed copy's filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR.KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(this section.red not be completed tithe permit la for one hundred dollars
($10()orless.) WATER HEATERW/VENT/ELFjCTR ENERGY FEE Y - N
I certify that tothe performance of the wink forwhlch this permit is Issued,
I shag not employ any person in any manner so as to become subjeetto the WATER SYSTEh1/TREATING
Workers'Compensation La sof Califomla. Date PAID
O Z Applicant NEW RESIDEN'ITAL PLMB. SQFL - Date Reml t# '
Z NOTICE TO APPLICANT.If,after making this Certificateof Exemption,you
'should became subject to the Worken'Comperxsatlon proviston of the Labor TOTAL:
res case,yesesmstfnrthmthc plymtbanrhpnwmnorthi pemdtahaube BUILDING II
9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d e Ihereby affirm
that there is aconstnctlon lendingagency forthe,perform- IOTA : ELECTRICFEE
C) �.-
Z once of the work for which this permit is Issued(Sce.3097,Civ. '
02 Leder'shame PLUMBING FEE !
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certifythat l have read thisapplicationand gate that theabove information
d iscorect.l agree to comply with all cityand county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives oftM1b
F (n city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,and emnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,Pdgments,costs and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 ami) SUBTOTAL:
ago ust Id City in consequence mile anting of this permit.
/�'�� —�4 9-i�pi AIRHANDUNG UNIT(OVER l0,000CFM) CONSTRUCTION TAX
ggo/IBJ o Applican/ etor 7 Date 77 FXETAUST HOOD(W/.DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bolding occupant store or hand le havardous HEATING UNIT(TO 103,O0o BTU) Date WRCCeI t#
material as defined by ted Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(a)7 FIEATGUMT(OVER 100,000 BTU) TOTAL: t"
❑Yes �]No
n -Will the applicant or future,building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
orderstand
hich emit ha,rardous air contaminants as defined by the Bay Area Air -FAR®
a lily Mangeant Disirin7 BOILER-COMP PI-I'OR 100,0(0 BTU) ffVV00
1 Yes ❑❑No 4luveread Health
ardou materials Se torsM ntsundernd 255 .I of BOILER-COMP(OVkR 100,000 tl7U). SEP 1 7 19181
rota health b Safety Code,Sectcora 25505,ve a t and 25534.1 J4r {that if the building does not currently havcatonant,that it is my NEW RESIDENTIAL MECH. SQ.PT
responsibility to notify the occupant of the requirements which must be met �{ aa�I
prior to issuance of a Certificate of Om pa ney. QY
� .Qpftno
Owner or authorired agent DateiSgU-D BY Z3A=A Www
TOTAL:
OFFICE COPY