22286 .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NO.
Building Address: - ^f,^(�
Okla Le 1 2228(
' ,
nen ame: ane A .
S�' S CITY OFCUPERTINO-BUILDING DIVISION / G
Conteactr'sName: Lic.N°: APPLICATION /PERMIT
BUMDINGELECTRICAL'UMBING-MECHAMCAL CAT'ORY COIQ
Archftect/Engineer: Lie.Ne:
_ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address r/s
PERMITISSUANCE ® 1l`LU
LICENSED CONTRACTOR'S pr DECLARATION
I herebySectioirm that 700E)olamlken3 ofthe under ssanvof Cssions 9(ocroomde,and c AI'PLIANCFSRESIDENTIAL JOB DFSCRE'TION
Tngwe is in full force
effeon3ofthe BusinessandProfeaslonsCode,and my l
license binas force and effect. PANF75 rja /j�fly.a�
DateLifteClav onto iJ�[�l V��0.
Date ContractorTo 200 AH5
ARCHITECTS DECLARATION 201-1000 AMPS
at I understand my plain shallbe used as publieremrds. OVERIOOOAMPS 5Q.FT.FLOOR AREA $/SQ.FC.'
O
SIGNS ELECTRICAL _ / LQC/ TCI ®�
og
�) Licensed Profredi ul `�L tJ l v 1l
H<a OWNER-BUILDER xempt ce DECLARATION SPECIALCBtCU1T/MIST
ti 2 IhercbyafRrmtOWNEER-BUILDRDELARAnthe etolsLicense lawfor the
7 O y following reason.(Seaton 70315,Business and Postmasters Code:Any city or
� countywhich rcqulresa permitmcorutosa,alter,lmprove,derrolbh,orrepair TEMP.MEHR OR POLE WSC. _
anystm=mpdortoitsissuance,alsorequRatheapplkantforsuchpert tto POWER DEVICES
E rNEE 0 file a signed statement that he Is licensed pursuant to the provisions of the
�3wG Contractor's License Law(Chapter 9(commencingwith Section 70W)ofDivi- SWIMMING POOL ELECTRIC /1 1
05 sron3mthe Buslnessand ProfemlonsCode)orthat he is exempt therefromand —� `j �A M ass"
❑5p S2 , the basis for the alleged exemption. Any violation of Section 7031.5 by an urLETs swi.ICHES}7XNRFS
appBant fora permit subjects theapplicantto a civil Finally of not moretlun co
r, O ive odreddollars(5500). SQfl'.
6 R NEW RESIDEMIAL ELECTR TYPE CONSTRUCTION
G1 �n owneroftheproperty,orhe employeeswithwagesas rthelesok � �Ij '
c pensatlon,wiildothe work andthe strocturc lanes intended or o(lered(or L
J O e(See.7W4,Buskiess and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves;thereon,and
CC who does such work himself or through his own employees,provided that such
improvements are not intended oroffered for sale.if,however,the building or TOT
impmver ntda ldwithnoneyearofcompleton,theowner-builderwlllhave ,
the Wrdenofpmving that he did not build orlmprove for purpose ofule.). QTY. PLUMBING PERMIT rribi APN
1 ❑L as owner of the property,am exclusively=trading with licensed I PERMIT ISSUANCE - i
contractors to construct the project(Sec.704;Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contract for such p(ojeats with a ALTER-DRAIN&VENT MATER(EM
t mAactor(s)Bmmed Pursuant to the Contractor's License Law. FEE SUMMARY
Lj I am exempt under See. B &P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDEFEES
Owner Date DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N
RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
t. ❑I hereby affirm that I have a certificate of consent to self-insure,or it _
cortiticate of Workem Comperwatlon Insurance or a certified copy thereof(Sec. RECENT
KMp
MW,Lab CJ GAS FAW
RA. C.40ITfLE15 PARK FIX N_
Y_
PRECEIPT M
Policy tl
S
GAEA.SYSl'FM-0VQt 4(FA)
Com any BUILDING DI VISION FEE
�CertBied copy is hereby filed
the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Cerll(ied copy la tiled with the city inspection division. QQ
CERTIFICATE OF F)EMP'FION FROM WORKERS' GREASE TRAP PAID(-� `- S1 . '1Z
COMPENSATION INSURANCE —l`'
(Chlssedion need nor bmcompleted Btheperndt Lsforom hundred dollars 56lVFR-SANITARY-STORM EA.200FT. Date Recei t
($1W)mless') - WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I cenRythat in the performance of the work for which this permit Is issued,
'I shall not employ any person In any manner so as to become subject to the WATIIt SYSTIM/TRFALLNG
Workers'Cempensation laws of Caiufernis. Date PAID
OZ Applicant NEWRESIDENT[ALPLMB. SQ.FT. Date Recei t#
O
Z NOTICE TO APPLICANT:If,after making this Certificate of option,you
should become subject to the Workers'Compemaat ion pm mi=of the Labor OT
N Code,you most forthwith comply with such provlalom or this permit shall be BUILDING FB
Wj deemM revoked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyafnrm thattlere isamosfromen lending agency for the perform- TOTAL ELECTRIC FEE
D Z ance of the workfic which th la permit la Issued(Sec.3097,Civ.C.)
U0 Lenders Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PER
FEE
LL U Icertify that l have read thlsappBcatbnand satetat htheabeve information MECHANICAL FEE
O w is comet.Iagree tocomply with all city and county orFRIT
dlnancesandgatelaws PMISSUANCE Sys FEES PAID:
} M relating to building construction,and hereby authorize representatives ofthk
F N city to enter upon the above-rrcnBoned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indermd fy an d keep harmless the City of Cupertino Date Receipt#
V against lUbillties,Odgmems,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
gairutnid Try 1,cor ceoftNt granting ofthis permit. AIRHANDLING UNIT(OVER IQMCII) CONSTRUCTION TAX
LOy� CONSTRUCTION TAX'PAID:
Sig rco ppBcant/ on Date IXF3AUSC HOOD(W/DIKT)
HAZA DO US MATERIALS UISCLOSURF
Will the applicant or future building occupant store or handle hazardous HFATINGUMT(TOINEY)OBTU) Date Reaei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER IW,000 BW TOTAL:
❑Yes 0 No
Will the applicant or future building Occupant use equiprrcnt or devices VENTILATION FAN(SINGLE RESIDE a ISSLJAN(y,QATE
which emit hazardous air coma mirants as defined by the gay Arca Er �"-F1
Quality Ma wgement District? BOILER-COMP OFN OR 100,IXq BTU)
E?Yea idj"° 2 4 1991
`{California malt rafetyCdous ile.Se reons 2555,2553 aChapter. 1 of BOILER-COMP(OVER100,000 BTL) OCT ,
theCaliforniata1t that fifth bSafety Cade,nor curre25505,ve tnaond.that. I l!
understandyton tifytheocculding does
ant of therrche uireenritswhichLthatitismy NEWRESIDENHALMETH. SQFL ERTINU
eapr to Issuance
ofaCeho occupant of0c( panty.lrcment which most be met CITY OF CUP C7%.B
prior to Issuance O(a Certificate Of Occvpanry. OTOwner or authortmd agent Date A ISSUED BY-.
OFFICE COPY