22661 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pee'ect Identification _ PERMIT NO. -
Building Address: 22661`X
L24 -5 L-1►�VA ANn� Cr.
wnersName: one: APPLICATION SUBMITTAL M=
gG.CftT -DIyor4 4o€'e]36-9123 CITY OF CUPERTINO-BUILDIN DIVISION ta� -2
Contractor's Name: LIc:No: APPLICATIO91 I E IT -
IFErchited/En neer. BULDING-ELECTRICAI lP B G-MECITAtilCAL CATEGORY CC=
8i CI6aa1C'Nv'r Lie.Noi
QTY ELECTRI 'P R I - FEE - BUILDING PERMIT INFO
Address."� a41J TCaee�' 9s�Z.SULDC
PERMITISSUAT4,T,
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Beensed under provisions of Chapter 9(commonc APPLIANC E 1, JE
OB DCSCRIPTfON
Ingwlth5 ion7000)of Uvislon3ofthe Buslnessand ProfesslomCode,and my
Itcense le In full force and effed. P FN Y'-e I�wU�
Limnse Class Lic.X �,J
Date Contractor
ARCHITECI'S DECLARATION I AMPS
�qqp±±rcO zp I understand my plans shag be used as public records. 1000AMPS - SQ,Fr.FLOOR AREA /�$//SSQ.Fr.
Q
E �j Licensed Professional GNS ELECTRI L - q (31
<<�
<N OWNER-BUILDER DECLARATION WEClALCIiCUIT/M19C T _ v
z m p,�F, Iherebyaffl.that l am exempt from the Contractor's License law for the
02g@� cwntywhich requires permit following reason.(Section 7031.5,Business and Piofesslons Code:Any city or
TEMP.METER OR POLE INST.
conslncy siren improve,demolish,or
any structure prior to its issuance,also requires the applicant for such permit�C to POWER DEWS Ile a signed statement that he b Ikensed pursuant to the provinces of the -
Ow� Contractor's License Law(Chapter 9(commencing with Section 7000)of Diel- SWIMMING POOL ELECTRIC
sin 3 ofthe Buaineesand Prefembm CodOmthat he is exempttherchomand VALUATION
IG3g5 �.' the basis for the alleged exemption. Any violation of Section 7Q15 by any O�.�a
G a licant for permit subjects the applicant to a dvil 1 cd more than f11LE7S5NTTCF&SFIXTURFS V
po five
P E PP penalty . '� S J s
five hundredou of hepr. NEW RESII]ENTIAL ELECTR
MI,as owner of the property,or my employees with wages their sole �'�' STORIES TYPE CONSTRUCTION
com(Sec.70KBusdess and Professions
rvdureisnot Nractor or iofferedfor
O sale(Sec 7094,to Busan iness and Professions Code:The Contractors Umrae Law
docs$ whodot apply torkht nrOfthu ShMsrty budids empoyeepp veidedkhatand OCC,GROUP RES.UNITS
whodoessuchworkhimsencled rasgh Maowsia.IL owe,providedildingor
Improvementsarenot Intended mofferearofc foraale.thh mer-buflderwilI have
TOT
ImprovemenHssoki wlthinoneyearofcompletion,<heowner-bugderwill have
the Inerden of proving that he did not build or improve for purpose of sale.). PLUMBING PERMIT
[_I 1,as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE sa ry P p, B E R
contractors to construct the project(Sec 7044,Business and Professions Code: NW`pVD6tlAl ItgVB
The C'or impO License Law aces not apply to an owner p property who ALTER-DRAIN&VENT-WATER ffN
j.
builds'tu Improvn thereon, and who contracts !m such projects with a
�'�p�factor exempt
d p under Sm
the COntrador'e Llmnse Lew. BACK FLOW PROTECT.DEVICE RY
(_J I em exempt under Sec B&P C for this mason
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N
Owner Date RECEPT X
WORKMAN COMPENSATION DECLARATION'
❑I hereby affirm that I have a mttlBcate of consent ro self-Insure,ora FIXTURES PER TRAP �� SCHOOL TAX Y N_
mAifi-teofWorken'Compeneatlonlruurancemacertlfledcopythercof(Sec. GAEA.SYSTEM-1 INC.60[T1LEI5 PARK FEE RECEIPT
3800,Lab C.) S X
'
Polity X GAS EA.SYSTEM-OVER 4(EA) RECEIzr N
Com any BUILDING DIVISION FEES
�Certifud copy is hercbyth the cid. CREASE/INDUSERL WASTE INTERCEPTOR PLANCHECK FEE
CertBled copy b(lied with the city inspection division.
CERTIFICATEOFEXEMPfION FROM WORKERS' GREASE TRAP "` PAID
cebe COMPENSATION INSURANCE SEWER-BAMTARY-STORM EA 20017 Date Recei tM CAI
(Thlactlon need not completed the permit later one hundred dollars
(8100)or less.) WATER I-IEATFR W/VFM/ELFCTR ENERGY FEE Y N
I cemlythat in the performance ofthe week forwhich this pemut b Issued, —
I shall ned employ any person in any runner so as to become subject to the WATERSYSTEM/TREATING
Workers'Compensation Laws of California Date PAID
O Z ' Applicant - {.]
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tB til fix
Fshould become sub)ect to the Workers'Compensation provisions ofthe Labor TO
V2 Code,you must forthwith comply with such provisions orthb permit shall be
LU > deemed revoked. - B eQB
CONSTRUCTION LENDING AGENCY $ $ E
CL
]hereby aRimnthat there baconsWdlon lending agency for the perform EL E
D Z ante of the workfor which this permit is Issued(Sec.3097,Civ.C.) TOT F�
U O lender's Name PL BIN G FEE
U. LendersAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O I metlfy that have mad this applicabon and sumthattheabove Infumatim
Ct WlscormR.Iegreeta complywlthallcttyand county ordinances and state laws PERMIT ISSUANCE �� FEES PAID:
U) relating to building construction,and herebyauthorize representatives ofthls
1" W ' city to enter upon the above-mentlnned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino ate celpt#
V against liabilities, custsand expenses which may In anywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUB OTAL'
Id City in con nm he granting of this penult AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION X
a—. —
Sig to of Apph..t/ .trad.r Date EXHAUST HOOD(W/DUCI) CONSTRUCTION T XPAID:
HAZARDOUS MATERIALS DISCLOSURE'
ill the applicant or future building Occupant store or handle haaardous HEATING UNIT(TO IDg000 BTU) Date R Pi t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,0(0 BTU) TO
M Yes No
Will the applicant or fu ins building Occupant use equipritent or device VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
whkhemit harardom air contamimnts cue de0ned by the Bay Arca Air ,
a ley Management DbtridT BOILER-COMP DHPOR 100,000 8TU
f Yes ❑No
have read the hazardous materials requirements under Chapter 6.95 Of BOILER-COMP 100,000 BTU)
t PAID
the Callfernb Health&Safety Cade,Sections 25505,25533 and 25534.1 - FEB
understand that if the building does not currently have a tenant,that it is my NEWRESIDENMALMECH. • SQXT. " 03
responsibility to notify the Occupant of the requirements which must be met 18
prior to Issuance of a Certificate of Occupanry.
- cirr o�cuN r
Owner or authorized agent Date ISSUED
TO
OFFICE COPY