22192 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_ Building Project Identification PERMITNO.
j .din"' :
ZiCrs Lp RoaFF Cr. 22192 21n2
caner. ame: . one.
- 9179.7111775-A717—
kLZV GREeTj 9'1 —931 CITY OF CUPERTINO-BUILDING DIVISION S�•�
ContradeasName: Ue.Nu APPLICATION /PERMIT <
SYR ROT S C N 7. 1591(.o BUILDING-ELECTRICALPLIIMBING-MECHANICAL CATEGORY CONTROLN
Architect/Engineer. Ltc No:
r`EO 'D 00 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO-
Addre, 69 Sul.io AVG-. .S PFRM1BTISSUANCE
LICENSED CONTRACTOR'S DECLARATION El
I hereby affirm that l am licensed under provisions of Chapter9(mmmcoc- APPHANCESRESIDENITAL JOB DIESCRB'ITON
Inense 1.ectlon force and
and my ,x s- „ 1 -e-� �i
license lain Tali force and effect. PANELS '-}) [N\`/^�l\'1`-Y`'-'\/�� t I
Liconx Class Lic.N
Date Contractor UP 10 2DO AMPS
ARCHITECTS DECLARATION 201-1(1W AMI'
��ZO I understand my plans shall be used as public records. OVER 1000 AMPS - - -SQ.i[7JFLL b/SQ.IT.
<d E Licensed Professional SIGNS ELECTRICALI(,—^
�
Q OWNER-BUILDER DECLARATION I x- ' '• � ) 0 Wr it Ig''1'n E7 SPECIAL CIRCUIT/MIST I l�
owing rasorntbrtlam exempt Fromthe Contractors License law fort he ^� �s
0O Q
following ichreq(SMfon eit$Bustruct and Professions Code:Any dty or 7FMPMEITR ORPOLEINST. DN E /3 ! I
' <W countywhire mquireastaganealsorquirestheapmvgdertnlbh,ormit to 1
anystmcturc pmorto Its(ssuance,alsorequlreslheappOcanl for such permit to POWER DEVICES -
O c O file a signed statement that he is licensed pursuant to the provision of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION .
F•�OS sion 3 ofthe Business and Professions Code)or that he is exempt therefrom and .
the basis far the alleged exemption. Any violation of Section 7131.5 by any ('1 1 fy-.t L n'Y�)
s a OUT7ETSSWITCHESFIXTURES L` W I.CJ
O
applicant permit subjedsthe applicant civil penalty otos rtnrethan
.. Eve hundred dollars(SW. NEW RESIDENTIAL ELECTR
�n ❑],as owner of the property, employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
P Penh•or he emP°Y B
sale( sam44,Buldolheworkaessio stmctureisnot intendedo iofferedfor
O sale(Sec.apply
to a now and PMexlom Cede:The Contractors License law
does�j whod apply torn owner of properthrong his one ds mpor imprewes thereon,yees,povidedthatand
P-S^ whodansuch work hlmxBwthrmgh hisownemployns,provided that such OCC.CROUP RFS.UNITS
Improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL:
improvement issold within oneyearotcomptetion,the owner-bulldcrwili have
the en ofproving that he did"whuild orimprove for purpose of sabJ. QTY. PLUMBINGPERMIT FEE FLOODZ0NE APN
,as owner of the property,am exdwlvely contracting with licensed PERMITISSUANCE
root ors to mnsW ct the project(Sec.7044,Buainesa and Profenbv Code:
The Con car's License Law don nal apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
Wilds or Improves thereon,and who contracts for such projects with a - -
o tt ctoKs)Bmnxd pursuant to the Contractors Llmnse Law. FEE SUMMARY
iJ 1 am exempt under Sec. B 6a P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COMO. SANITARY Y_ N_
Owner Date RFGF71'f N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby aRtrm that I have o certuranc of consent to self-Insud,ora RECET T N
3800,1 cam C.) rkers'Compematlonlwuranm ora certified ropythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy 0 C.) RECEIPT N
Policy M GAS PA.SYSTEM-OVER 4(EA)
Com any � .BUILDING DIVISION FEES
�
Cedified copy is hereby Famished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK PEE
❑Certified copy Ls filed with the city Inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.MFT. Date Rett`] tN
RhisseRion need nct be completed lithe permit is fororle hundred dollars
($10(derless.) WATER HEATER W/VENT/FI.FL]R ENERGY FEE Y_ N_ ,
I mnitythat In the performance of Ne work forwhlch this permit Is issued, "
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California Date PAID
OZ ApplicantNEWRESD ALPLMB. $QF• Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Comperuatlon provisions of the Labor TOTAL:
(q Code,you most forthwith comply with such provisions rrlhis permit shall he
W > deemed revoked. BUILDING FEE x
Ei CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hercbyafBrm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
7Zante of the work for which this permit is issued(See 3097,Civ.C.)
UO_ .tier's Name PLUMBING FEE
r Lendersnddreas QTY. MECHANICAL PERMIT FEE
O W I mrtdythatl have read this applicalionand statethattheabovelnformation MECHANICAL FEE
is correct.,I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W elating to building rorsuuction,and hereby authomze representatives of this
I.- Z city to enter upon the above-mentioned property for lupectlmn purposes. ALTER OR ADDTO MECH. Date Receiptq
(We)agree to save,Indemnify an d keep harden the City of Cupertino
V' against liabilities,Judgment,costsand expenxswhlch mayln anywayaccrue AIR HANDLING(IMI(TO 10,000CFM) SUBTOTAL:
agai aid in con of the granting of this pemdt.
AIR HANDLING UNIT(OVER 10,000 CFM] CONSTRUCTION TAX
$•Li-5I CONSTRUCTION TAX PAID:
ig,ature
HAZARDOUS
Date IXHAl15T HOOD(W/DIK'D
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orthe ue ttinoM Municipal Code,
h handle hazardous HEATING UM7(TO 100,ODOBN) Date RCCejptiY
materialas Safety by oche Cupertino MuNcipalCodeChapter 9.12,and the
Pleallh and Safety Code Section 75537(a)t HEATING UNIT(OVER l00,OW BTU) TOTAL:
❑ Yes r fu No
ur
Will the applicant or(ulure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$UANGE DATE
which cost havrdous air contaminants as defined by the Bay Area Air 4'' /:f
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) CP
❑ Yn ❑No /eFM y
Ihave read the hazardous materials requirements underChapter6.95 of ROILFR-COMP(OVER 100,000 BTU) "Ir1� pr n
the California Health ASafety Code,Senimv 2550.5,25533 and 75534. 1Japes]
n
understand that if the building donot currently have a tenant,that it is my NEW RESIDENTIAL METH. SQ.f7. V='•
priors isso.oce'd Certiompantofthe racy. x:nb which most be met �/�v_
prlFeasivity to notify
thcccdtof past.p.racy.
Owner or authorised agent Date ISSUED BY:
TOTAL:
OFFICE COPY