22851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentifiution PERMIT NO.
Budding Addma: I"1/�(�
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CITY OF CUPERTINO-BUILDING DIVISION _ q
tramcar's ams: ue./Nre: APPLICATION /PERMIT L
-I BUILDING-ELECTRICALML BIN' -MECHANICAL CATEGORY CO 3
��
Ilett/En neer. Uc.No:
IE:- QTY ELECTRIC PIT FEE BUILDING PERMIT INFO
Address: GI^ '^ q / PERMITISSUANCE � 1�'i
LICENSED CONTRACTOR'S DECLARATION T `
I hereby affirm that l am licmsed under provisions of Chapter9(commenc APPUAN ENTNL JOB DESCRIPTION
Ingwlth Sectio 7000)of DtWsion3oflhe Bualnemand Pmfnsms Code,and my
license is In fu and effect PANE/ Hyl,. I
LicamDate Ciass _LION��i�I^ - 1 l�✓
Date Contnttor Ice�syQ '
ARCHITECT'S DECLARATION -1000w IV
rc0 Z I understand my Alam shall be used as public records VER 1 SQ.FT.FLOOR AREA s/SQ.FT.
HO _
E Licensed Professional GNSE C L 7 2 ��y�O
Q^� OWNER-BUILDER DECLARATION IA C T/ �J _l
IherebyefRrmthat l am exempt fromthe ContraRor'sLlcense Law for the
O 9 H following reason.(Settlors 7(815,Business and Professions Code:Any city or METER L N
�,yp� countywhichrequimapem ttoronstroM.1t,r,bnpt ,demolth,orrepa+r
a S¢ anystmomm Inferno its issuance,aborequlrestheappllcant for such permit to p0 DEVICES
Q 3 F file a signed statement that he is licensed pursuant to the provtiom of the
w
Contractor's Lice.Law(Chapter 9(mmmencing with Section 70M)of Divi- SWINMI LEL
O ston3ofthe Bustemand PmsfembroCmde).,than heisexem therefromand VALUATION
H
the basis for the alleged exemption, Any violation of Section 7031.5 by any -1 O�E�
7o a c�
9<� applicant for a permit subject mre
the applicant to a civil penalty of not otheo lt3
F five hundred dollars($500).
I as owner of the property, NEW RESIDENTIAL ELECTR_SQ.FT, STORIES
C 6 °❑ e, perry or my employees with wages r thele sole ( TYPE CONSTRUCTION
compensation,will andthestruce:Thecture Is not btended License
eLaw 2 S
�a� d for
O sale(Sec.7644,easines...d Professions Code:The Codtrectots Urewe Law
p$R does not apply to so owner of property who Wilds or improves thereon,and OCC.GROUPRFS.UNT7S
who docs such work himself or through his own employees,provided that such
improvement are oot Intended oroffered forsale.If however,thebuilding or TOTAL:
improvement,sold wlthlnoneyearofcompldiogtheownerbu0derwlll have
th.Ameden of proving that he did nor build or improve for purpose ofsale.). QTY, PLUMBING PERMIT
U I,as owner of the property,am exclusively contracting with licensed coppRMIT ISSUANCE f
contractors to construct the project(Sec.70(4,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilda or Improves lhemer, and who contracts fee such p(ojects with a
ogOL�ador(s)Ilconsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE _
L lam exempt under Sec B k P C for this reason
UA
Owner DRAINS.FLOOR ROOF,AREA,CONI. 1a'(' SANITARY Y N
Date RECEIPT
N
WORKMAN COMPENSATION DECLARATION FE(TURES PER TRAP rs W gp{ppL Tp)( Y_ N_
,c❑I hereby a(flrm that I have o certificate of consent to pythe re,ora J RECEIPT N
ertlficate of Workero'Comperwtlonireurmceora ceml(4d copythereo((Sec.
3800,Lab CJ GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
Policy N
RING TN
Cam ny GAS G.SYSTFM-OVERd(FA) BUILDING DIVISION FEES
rtlfied copy t hereby GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy t filed with the city Inspettbn division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP _ PAID �f `,'�U
COMPENSATION INSURANCE
(I'hlssedonnced not becompleted lithe permit tfe teehundred SEWER-SANITARY-STORM dollars STORMEA.200FT. co Date Recei t#
($100)orlevJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that o the performanceof the work so as to b co eem bj Is bared,
I shell not employ any person In any rtunner am as to become arbjett to the WATER SYSTEM/TREATING Q�
Worked Compensation laws of California.Date P
O Z .NOTICE NEW RE9DENTIAL PLMB. SQ.FT. Date Recei t#
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Compensation provisions ofthe Labor -ALT
N Code,you most forthwith comply with such provisions mthb permit shall be
LU > deemed rooked. BU
a p CONSTRUCTION LENDING AGENCY S EE Cb
= Z a Ihcrcbyaffirm that there b a corutructlon lending agency for the perform, TOTAL EL RIC FEE
nm of the work for which this permit t Issued(sec.3097,Civ.C.) QT O
U O enderbName PLUMBING FEE
LL I- Ieddcr's Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1odify thatI have mad this application and state that the above information [,17
S Is rorreR.lagmto comply with all cityand county ordinances and state laws PERMIT ISSUANCE (� FEES PAID:
} relating to building romtruction,and hereby authorize expresenttives of this —1i It1,L.J`/�JJC/.
F Z city to enter upon the abcvomentioned pe for Wpectimn purposes. !o ALTFRORADDTOMECH.
V - (Ne)agree to ,In coned
mW armless the City.(Cupertino Date Celpt#
agelast Ilablliti g nts s msec which may In any wayacaue AIRHANDUNG UNIT(To 10,000CFM) SUB OTAL'
ag yin f among ofthis permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TA
tumo ppucant/Co ra or Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wiiltheappl+cantor(ummr ildingo pantstomorl Miehazardous HFATINCUMT(TOl00,W0871) Date R #
material as deflnnd by the Cupertino Municipal Code,Chapter 9.17,and the _
Health and Safety Code Ion 75537(a)7 HFATINGUMT(OVER10DDDOBTLD
❑Yea [vNm TOT
Will the applicant orfuture Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) LfISD ,ISS�UUAdNCE DATE
which emll hazard salt rod mined,as defined by the Bay Area Air U' r�
' Q�rality Mawge nt Dit ' BOILER-COMP(3FB'OR 100,IXD BTU) ® N
TTI Yes No
have read eheza cam matcmabrcqufic e ' underChaptcr6.95 of BOILER-COMP(OVER l00,ON BTU) �A '1 [a ���
the California Icalthk Sa(sty Co dr SrcfiIL 755115,25533 and 75534.I (// 1 O
understand Id'11 11.n.ie Wllding docsn rrcntly haveatenan6 that it NEW RESIDENTIAL MECH. SQ.F7 ^
rrsponsibll to notifythe oc nt itherequlrcments whityby ty�yeee mM O -CIlY OF Cl/ftt,I INV
prior to' aposofa CcrUfy cof cups 1- // /r/ La
Owner or authorized agent Date ISSUEDe
OTA[ N�
OFFICE COPY