22065 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Pm 1dendf"drs PFILMT NO.
Building Add 22065
e ams one: Alq��HUN
A
P CITY OF CUPERTINO-BUILDING DIVISION
Cm��ra{�o,'s Nanx: O{ Lir.No: APPLICATION I PERMIT
`N BUILDINGELCC7RICA4I'LIIMBINGMFLHAMCAL CATEGORY CONTROL/
ArehBeet/En neem Lir.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.' PERMATISSUANCEE:1 1:11:1LICENSED CONTRACTORS DECLARATION -
Iherebyafflrmthatlaml:cenudundupr Ww.ofCiapter9(oomrnenc APPLLkNCESREEMiAL JOBDEC
Ingwith Se .7007)o(DtvWon3ofthe Budin .dPmfe..Codgandmy
Ilans hi in full d
//3
d(eG. PANELS
n,e.?C?Qy�lk.. •s�'r3 y1J1�_(„I K
Date Contnnor UP TO 2DOAMI-5
RCH 5 DECLARATION 7(11-100AMPS
0
OZ I�g . ed �ii {Ie remNe OVER iWO AMPS SQ. 5/SQ.F7.
L B�NBFrR at P U T E R
OWNERER BUILDDECLARATION
Ihertbyafflmnthatlamexemptfumme Contractors Ll¢nselAw(or the SI'ECIAI,CIRCUIT/MISC '
po followingmason.(Sedlon7MIS,8whessand PmfrwlonsCadr.Anydtyor
O 2 Fair TEMP.ME ER OR IDLE 1NST. {
K muntywhbhre toiapemJt o6 muqu tr sap Uv if su&orrepto
DAM
any ahucture statement
ltelsu.nse,e emaied besmant to the pro amens of t e
O aIle a Ygned datemrent that he b Boerued puruant m the proWebro of the POWER DEVICES
Contrautorb Liceme Law(Ctupter9(mmmendng with Section 7DOO)of DEW- SWIMMING POOL ELECTRIC
3p aon3ofine BuMmand Pcofmlom Code)orthahelseu merehomaM - VALUATION
5 the bails for me alleged exemption. Any Wolaflon of Scab MIS by any OUTLETS-SWITCHES-FLXTURES
appliant for a permit subjects the appilraot to a dWl penalty W not more than
flv�f odred dollars(SW.
..�m
U1,u owner of the property,or try employees with wages u their sole NEW RF�F3JTIAL ELBCTR SQFI. STORIES TYPECONSTRUCTION
mmpem - at dothework,andtheatruGure lanes lyderdedor offered for -
Osale 0ac 7044,8..and Pmfesslons Code:The Contadoe.License Law
does not apply to an� owner of property who Wilde or lmpm es thereon,and OCG CROUP RES UNITS
s^ who dosuchwork hhraelforthremployees, mv
sos employ ,pided that arch
n
improvements arc net Intended or.ffered(mule.If,however,the W ilding or TOTAL
Improvement bsoldwNEln oruyearafmnpleUor�,theowner-0ullderwlll Five
tlrLkurden of proWng that he did not build or improve for purpos of uta.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L a owner of the property,am erchnhely,contracting with Named
nt.a.to cotn
muct the pmject(See 70K Budnm and Profesilons Code: PERMIT ISSUANCE
The Cor actors Lloens Law dm nor apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
builds or Imp.thereon, and who mm ntrafor sueh p -
tojeta with . FEE SUMMARY
�+dor(.)Barued pursuant to the Crntnctoes Uss erLaw. BACK FLOW PROTQ.T.DEVICE
LJ I am exempt under Sec B 6 P C for this reason �ry
Owner Dae
DRAINS FIooR ROOF,ARU,COND. 2.�(/ SANITARY Y N
RECEIPT E
WORKMAN COMPENSATION DECLARATION
K
❑1 hereby affirm Wt I have•aureate d crmm�t to self-buns,ar a �S�SAP 54100E TAX Y N_
artiBots cfwarkea'Compemalon Imuran a•amtified copy thereof(ec. REGF�rf�
3g00,Lbc GAS EI.SYSTEM-1 INGl OUTLETS PARK FEE Y_ N_
Pyle,R RECEIPT Y
Co ny GAS EI.SYSTEM-OVER/(EA) BUILDING DIVISIONFF.F.S
Certified mpy b hereby furnished. GREASE/INDUSlRL WASTE INTERCEPTOR PLANCHECK FEE
❑Cert8led ropy b filed with the efiy Impectbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFA.SEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EI 7DOFT Date Recti t#
hank vertion need not be compleed lithe permit b/a one hundred dollars
(SIOD)alemJ WATER HEATER W/VF /01=CTR ENERGY FLE Y_ N
Iartifytpatlothepedorn moftheworkforwMchtN pemdtlshued,
I shall not employ any person In any manner m u to become ubjed to the WATER SYSTEM/TREATING -
waken•CompensanonLaws ofCalifaw. Dae PAID
Q Z Applirant NEW RESIDENTIAL PLMB, SQFT. Date RC i t#
Z 0 NOTICE TO APPLICANT.If,after making thls Certificate of Exemption,you
should becomesubject to the Worker?Compensation provlsbns of the Labor TOTAL:
N Code,you crust forthwith comply with such pmvlsbns of this permit shall be <�YT NN/Y� [nom"\ L�
LU > deemed revoked. BUILDIN -
a c CONSemisa ONLENDING AGENCY IC FEE
I hereby affirm tbt mere ls•mnswNeh krdingagency forthe pedomn ECT FEE
M Z anmofineworkforwh hthlspemNtlsla (See309'7,CH.C.) ATOTAIL,0O Lender.Name PLUMBING FEE
LL — LendrreAddress QTY. MECHANICAL PERFEE MECHANICAL FEE
OW Iartlfymalhaveaadthlsappli nardaatemattheabovelnfom dos
a bmrnai.Iagneetocomplywithabdtyand v ntyordWnmandrtatslaws PERMIT ISSUANCE FEES PAID:
relating to Wilding construction,and hereby authrrfm represntatNn of this
F N dty to enter upon the abo ementlom i property fee inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,Indomrd an d keep harmless the City of Cuprrtlno Date Receipt#
V age Wt tiro,' gmenu, amd expense which may In any way.ra„e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
age Id ria fthe gr.rumg dtM.N
ATR HANDLING UNIT(OVER 1R=CM CONSTRUCFIONTAX
tureof Ap ant ontract Date E70UUSf HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS d.TER1,0kLS DISCLOSURE
WWmeappBcarrtwNwmbuUdingo pantstomorlardleha ous HEATING UNIT(TO 100,0006T1n
material as deflvd by the Cupertino Musidpal Code,Chapter 9.12,and the Date Reeei t#
ma
Behnan Yaannd SafetyCod,eL�L++--����S tIon Mn(.)? NFATwG UNIT(OVER IOQO(10 BTU) TOTAL:
�JWthrapplkantmfuture Wlldingar pantumNulpm mint devices VENTILATION FAN(SINGLE RESTD) ISSUANCE DATE
which emit hazardous air mnl.mianu as deft eci by the Bay Area Air
Quality Management DktrN7 BORER-COMP OIiP DR l00,IXq BTU) PAM
Y.
No
4u ecoid the h..materials nequinemznu under Chapter 495 of BOILERCOMP(OVER 100.0110 BTU)
the California Health k SafetyCode,Sections 75505,75533 and 75534. 1 .-q rat y at 'IQQ�
undentindthat if the building don rot ammently have a tenant,that It is my NEW RESIDEMIAL hfECli SFT
mpomaibelty to rally the occupant a the requirements which must be met
prior to lseuana d a Certificate of 0imupaay.
1
Owner or authomed agent' - Date ISSUEDB
TOTAL
OFFICE COPY