22745 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Ad . 1 '4745
S
e Name: one: A
w r. CITY OF CUPERTINO-BUILDING DIVISION
c°torso°' Nam : - Lic•N. APPLICATION /PERMIT //
71 Aq1
ArchlleR/En neer. v BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY, C OL#
g Lic.Na
`� iBUILDING PERMIT INFO' '
Y.`' 'RMITISS[IANCE£LBGTRIGPERI4[IT -.: 'E$ -"
Address: PE ❑, Ir7( ❑
LICENSED CONTRACTOR'S DECLARATION qIL�
I hereby ion7OODatlam Bcen3oftheused under pmmands°(Cssioha9(coand my AFPLIANCESAFSIDENIIAL OR DESCRIPTION
hear.h Infull forces daffeon3ofthe BuslnessandlPro(easionsCode,and my /�}f ��j) �,.• n �.
Licenelalns force and affect. _ PANELS /•LiI�I (� s y
LicenseChee Lic.q �r YY .
Data Contractor UP TO 20OAhUS
ARCHITECPS DECLARATION '2014000 AMPS -
q�7 I understand my plans shall be used as public records. OVERlW0AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
G N .
SIGNSELECTRICAL-
tq�fi Licensed Professional '
GgGq u°�
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
L, followhereby ing reason.
Tam31.5,Business from the Contractor's License Code:Law fort he A •1 t /� �f�� gp T E R
Z O:J following reason.iSeaton rm11.5, Tact and alter,inip ove, Code:Any dep it - L, i V B C
OZ, � TEMP.METER ORPOLE INST.'
OZ ebunlywhichctere requires mit / �����
g any atmduretatorto ement that he
aicanseuiresthant to the for such provision of to POWER DEVICES '
CS r Tie a signed statement that he ra licensed pursuant to the provision of the
3wy Contractor's License Law(Chapter 9 Code)(commencing with xecion7000)herefof and SWIMX4NG POOL ELECTRIC
SOS the 3 of basis for tealle and xemptionC Any mthat
inexempttherefrom and _ VALUATION
the basis for the alleged exemption. Any violation of Section by any
appliantfor a permit subjects the applicant loacivil penalty of not not mom
orethan OUT1.ETSSWITCHESFIXT[B2FS
five hundred dollars($500). - NEW RESIDENTIAL ELECTR
1,as owner of theproperty, e"RFT• STORIES TYPE CONSTRUCTION
❑ k,a or my employee with wages r thele sole
compensation,Businetheworkandthe Code;TInotintendeda ioffered(or
O sale(Sec. pply Business and Profession Code;The or improves
License Law
jS
who ddom oes
applyloan owner ofpropertyhison emaoeimprovnthereoryand OCC.GROUP RES.UMTS
whodoes eats a.n himself ed orough hisownemployees,provided that such
Improvement issold ithindeeyearfered(orsale.themnv-gfiderwilI have
TOTAL:
Improvement baoldwithin oneyearo(compleiioo,the owner-bullderwlllhove
th11
�rden ofprovingthathedid not build or improve for purpose ofsale) QTY• '„ �PLUIvI$ING PPRMIT t t +•'•:FE£. FLOOD ZONE APN
I,as owner of the property,am exclusively matramng with licensed PERMIT ISSUANCE rr
contractors to construct the project(Sec.7044,Busineas and Profession Code: l
The Contractors License Law doe not apply to an owner of property who ALTER-DRAIN&VENT-WATER tliAl
Wilds or Improves thereon,and who contracts(or such p( -
oJects with a •FEB
actor0i)licensed pursuant to the Contractor.License Law, BACK FLOW PROTECT.DEVICE
SUMMARY.
LI I am exempt under Sec. B&P C for thin reason '
Owner Date DRAINS.FLOOR ROOF,AREA,COND. .. SANITARY Y N '
RECF]PT#
WORIGHAN COMPENSATION DECLARATION plX �c 1PFR TRAP SCHOOL TAX Y N—
[hereby affirm that I have a certlRate of consent to sell-Insure,ora RECEIPT#
A, cateofWorkeri Compenatlon lvaurance oracem(ledmpythereo((5ec.
3800Lein CJ GAS EA.SYSUM-1 INC.40UTLETS PARK FEE Y N,
'
P.hl, N A) RECEIPT#
Com any_ T.avv�..4.0 G.,i n GAS EA.SYSTEM-OVER 4(EA)) BUILDING DIVISION FEES
Werttfied copy is herebyfamished.the city GREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�I CertUied ropy b(fled with the city InspeRlon division. -
CERTIFICATE OF EXEMPTION FROM WORKERS', GREASE TRAP PAID
COMPENSATION cdlitINSURANCE SEWERSANR'ARYSTORM EA 200F1. „Date Reccl t#
(This section need eat becomplMed lithe permit I(Drone hundred dollars
($]I cimifess.) 1. ` WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Ill not that o an7 person in any
manner sa as t cern pesubjecrmit I.issued, —
I shall not employ an/person i"any manner eo as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawn of California.Date - PAID
Z Z Applicant -
Z O NOTICETO APPLICAN 1:It,after maki—this Cert—victeof Exemption,you NEWRESIDENTIALPLMB. SQ.FT. Date Recef t#
should become subject to the Workers'Compmsatlon provisions of the Labor - TOTAL:
N Code,you must forthwith comply with such provision orthis permit shall be
W j 'deemed revoked. - BUILDING •E
a CONSTRUCTION LENDING AGENCY SEISMIC FEE .
'I hereb
Z y afftrenthat there is a construction lending'agenry for the perform- �,ante ofthe work for which this permit is beand(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
c
V O lender'.Name - PLUMBING FEE
LL t- Lender'.Addrees QTY:r` '' ME(HANIOAI .PPR NIT + fEE'.'
O W Icerre
tifythatl haveadthis appliaMECHANICAL FEE
tionand statethatthe above information -
IL bmrred.I agree to comply with all city and county onlinances and state laws PERMIT ISSUANCE FEESTAID:
W relating to building construction,and hereby authorize representatives of this //..4 [vr . G�
1— Z city to enter upon the above-mentinned property for inspection Purposes. ALTERORADDTOMECH. L-L_�—1-L
V _ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date . Receipt#
against llabilities,judgments,mats and expenses which may In anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL,
17 -
against said City in consequence of the granting of this permit
AIR HANDLING UNIT(OVER IDp00CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,M0 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12.and the r�
Health and Safety Cede ion 25532(a)7HEATING UNIT(OVER IDg000 BTU) TOTAL: - /.
.1-1 Ye. No
WI..the applicant rfu m building occupant so equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air D
Quality Management Dist ict7 BOILER-COMP OHP OR 100,000 BTU) - P A '
❑Yes ,,.`�jNo
Ihaveread the hazKImaterlals requirements underChapter6.95 of BOILER-CAMP(OVER 10),000 BTU)
the 21vemla Health&Safety Code,Section 25505,25533 and 25534.] NOV �A �as#s�
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.rr �Ji sJ'y
responsibility to not lfy the occupant of the requirements which must W met `1
P Ito lssuaaceof Certl to o(Ompanry. �11 VF rt�TIIY�•
mer orawhortre agent JDate s
TOTAL: ISSUED '
OFFICE COPY