22660APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Pm en Identification -
Building Address; www. w
PERMIT NO.
22660
wnere Re ss;
[/ A/ 7�- s -h
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BNLDINGELECTRICALPLUMBING-MFG}IAMCAI.
�J
c°ntrsR'r.arae: Lie. No:
CATEGORY
CONTROI/N/' /' Z
ti!O�
Architect/Fsgin r Lk. No:
cJ
QTY
QELECTRIC PERMIT PEE
BUILDING PERMIT INFO
Address: W
PF]LMITISSUANCE
LICENSE CONTR under SDECLAR 1 N
I licensed PeovfChapterg
fthe Budneseand ProfeeloneCode,and my
cesCixieand
InenseI In fullforce and
Liensle In full force and effect,
License Clam Lisp
Date Contmtlor
ARCHITECTS DECLARATION
I understand my pians shall be used as public records.
Llmved Professional
OWNEReBUILDER DECLARATION
Iwingraffirm
son.(that lam31.5,Bsinexempt from the Contractors Code: Law for the
followingichmq(imapScetion 7 tt- uelnemand
r, fpmiw,Code:Mydtyor
rountywhich requlmea permit tomnstvct, alter,fmprove, derrolbh,orrepalr
anystmdumpriortoitslavance,aLwrequimatheapplimntforsuchper tto
file a signed statement that he to licensed pursuant to the pmvbiom of the
Commemes License Law (Chapter 9 (commencing with Section 7000) of Civil-
.ion 3 of the Business and Profemloa Code)°rth t he is exempttherefroma nd
the basis for the alleged exemption. Any violation of Section 7031.5 by any
m
applicant for a permit subjects the applicant to a civil penalty of not ore than
fly e ndrcd dolhn (g500).
PSQFT
I, a owner of the property, or my employees with wages as their sole
mpensatlon, willdo the work and thestvcture is not Intended or offered for-a-�)S
sale (Sec. 7654, Business and Professions Code: The Contractors Deems Law<<
does not apply to an owner of property who builds or Improves therms, and
who doessuch work himself or through Msown employees, provided that such
Improvements are not Intended oroffered formic. If, howevep thebuilding or
Improvement ismidwlthln oneyearofcomplebgthe owner-bullderwlll have
tilLturdes of proving the he did not build or improve for purpose of sale.).
Lj L as owner of the property, am exclusively contracting with licensed
mntracton, to construct the project (Sm. 7054, Business and Pr°(emiom Code:
The Contractor's License Law does net apply to an owner of property who
builds or Improves thereon, and who contra for such pioject, with a
Dosed pursuant to the ContoactlifiLicesse Law.
I mcarp, under Sec B & P C for bre n
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
1IFF��]]
S> pc>w�
PANELS
— UP TO 2DO AMM
1-1000 AMPS
OVERI"AMPS
SQ. Fr. FLOOR �A-RI-EtA
222 1
r L �}Y 1
'l
/�$/SQ. FT..
2(pa cyrt
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOLELECTRIC
OUTLETSSW ITCHESFIXTURES
VALUATION
/^/^
L 1 11 V a
NEW RESIDENTIAL EL ECTR _SQ.Fr.
STORIES
TYPE CON5IRUCTION
I^Y a
17
TOTA
QTY. PLUMBING PERMIT PEE
OCC.CROIIi'
RFS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
FLOOD LONE
APN
FEE SUMMARY
BACK FLOW OTECT. DEVICE
DRAINS R $
, CC (�. _E:
ID
RY Y N
RECFR'T N
Owner ate
C CLARATI N
❑1 off at I ha a ce e f consent to aelf-Io cr a
certlfi of Wor 'Compe uzanceoracealfiedeopythemoffSec.
3B00,Gb
Polley p
b7XIDRES PER! p
CAS EA.SY$TEM-1 ,4
LTA Y_ N_
RfLEI'fN.
A Y_ N_
4 REC= p
CAS EA. -0V -V/Ys aG
Y -
UILDING DI VISION FEES
Nay
NCertl(Icd copy hereby furnished.
❑Certl(led copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis.ection need oat be completed lithe permit iafor one hundred dollars
($100)orlem.)
Icenifyot that lnthe person
nce In
for at; boMepermltc issued,
1 shake not employ any person In any manner n a to become subject to the
Workers Compensation Lam o(Calif°mW. Date
Applicant
NOTICE TO APPLICANT: If, after makleg this CenBlote of Exemption, you
should became subject to the Wnrkers'Compensation pmvlalom of the Labor
Code, you must forthwith comply with such provialoruorthia pemrdtshali beD
decrrevoked.
decimal re
CONSTRUCTION LENDING AGENCY
IherebyafOren that there is a construction lending agency for the perform
ance of the work for which this permit b butted (See. 3097, Civ. C.)
I,ceder. Name
Lender. Address
1 sonify that I have read this appRmfbn end male that the above Information
b ourrect.Iagree to comply with all city and county ordinances and state laws
relating to building mnstructlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for izppwon purposes.
(We) agree to sive, Indemnify an d keep harrn]94Ae City of Gu pe Ino
agairut 11 Itlea, jadgmenG, corteand expense may lnany my c
ag mid in 1974uence af� a �a this permit
y I
GREASE/IND -WASTE INTERCEPTOR
PLA - GK FEE
PAID
Date Recei t#
52�.
GREASETRAP
SEWER -SANITARY -STORM EA 700F7
WATER I]RATER W/VENT/ELECTR
ENERGYFEE Y N
� l ��r Q^
,PAID CDL...
Date Remi t#
p
Zeal
WATER i SYSTEM/TREATING
NEWRESIDENTIALPLMB. SQbT.
TOT
t O
SEISMIC FEE — -/
L L 6
TOTAL
5
ELECFRI
PLUMBOME
QTY. MECHANICAL PERMIT FEE
MEC CAL FE
F•
PERMIT ISSUANCE
ALTER OR ADD TO MSCH.
Date Reeei t#
AIR HANDLING UNIT (to 10,000 CFM)
UBTOTAL•
AIR HANDLING UNIT (OVER 10,000 CIT1)
CONSTRUCTIO TAX
Signator fApplira rector Date
A RIALS SURE
Will t a.ppll 'tor futurcbtlldl antst or handlehazardoua
muerhla by4 no Municipal Code Chapter 9.13, and the
He❑alt Yaannd Sa sty Code Section 75533(a)7
s MNo
Will the applicant or future bcilding occupant use equipment or devices
which emit hazard., aU mntamlmnb as de0ned by the Bay Area Alr
Quality Management District?
Yea n❑ No
have mad the bazardou.materials, requirements under Chapter 6.95 of
the Glhfemla Health &Safety Code,Sectioru25505,35533 and 75534. I
understandthatiflhebuildingd°csrwtvrrc^tlyhaveatenanLthatitismy
resp to Issuance nosy theon
morto bilityhatua to mofa the ocvpantrzthe rnquirerrenta which must he me
IXHAUSTHOOD(W/DUCT)
CONSTRUCFIO TAX PAID:
BEATING UNIT (TO 100,000 BTU)
--
Date eCel t#
HEATING UNIT (OVER 100,000 JIM
%0TAL:
VENDLATION PAN (SINGLE RESID)
ISSUANG ATE
n 8
A ID
7- g
ISSUED B, 1�f
BOILER -COMP OHP OR 100,0W BTU)
BOILEROOMP(OVE1100,000 BTU)
ESI
NEW RDENTIAL MECH SQ.FI'
zc
Owner'rauthodd agent Date
^ ^
TOTAL 4� 1
.. v, �r111IYV
OFFICE COPY