22553 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro eM Identification PERMITNO.
Building Addg i . 22553
sones sme: ne - SU6Ml A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT 6 Ib
1M, tect/Engineer: LII-.IN. BUILDING-ELECTRICAL PLUMBING MECHAMCAL CATEGORY CONTROL N
`CCT11 R- MIT I +,'P -, ';Y BUILDING PERMIT INFO '
pTv; ;t',. RICPE ! ,� `; FEE .
Address ELEPERMITISSUANCE ❑' ❑
LICE EDCONTRA OR'S DECLARATION
I hereby af(um that lam ecmsed under provisions o(Chapler9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sedion7000)of Dlvtdon3 ofthe Buslnessand Pmfesslon•Code,and my
license lain and erfect+. „1 a�E PANELS �1 /
License la Lfc.NIY �
Date _GHITEC7
ARCHITEG wdD pARATIOrd OVEOff ODOAM
aO Zp Iundentand my plan shag be used apubllcrecords OVER 1(1!10 AMPS
C SIGNS ELECTRICAL �_
N Licensed Professional ���
�Q OWNER-BUILDER DECLARATIOiV SPECIAL CIRCUIT/MISC r j '
7s, owi'heng rssorm that la 7MI,5, tfrom the Contractor's License Law for Mycity he or
pp following reason(SeM1on 7031 S,Business and Profenloru Code:Mydty or Q��� /�I
OZt�e TEMP.MEEK OR POLE INST. -�E o Qp
county which requirma permit tnconstmct,alter,improve,demolieth,orrepair 4
qqq nystructure pdorto its issuance,also requirestheappBcant for such permit to ROWER DEVICES
file a signed statement that he V Licensed pursuant to the provisions of the
Qµ Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC VALUA
30�< kon3 ofthelfusiness and Profeaeoru Code)orthat he is exempt therefromand
•-+ the basis for the alleged exemption. Any violation of Section 7MIS by any +� ��►-F)
{g� «A aPPllrant tura permitaubjects the applicant toadvll penalty Mna morethan OUTLE7SSWITCHESHXTURFS
E ti hundred neroftdollars(epm NEW RESIDENTIAL ELECTR SQ.ET. STORIES TYPECONS7RUCTION
GG1l ❑I,as owner l the property,or he employees with wages r chert sale
wmpec.70K wW1r.an P endt..Codureh nm Intended or of.Lfor
sale(Sec.apply
too noss and f property
Code:The Contractors License Law
S� whododoes tapply torn ownerofprough who bulmplds orimprovnlhereoRand OCC GROUT' RE&UNITS
EE whodoem nts are out msel(othwgh hisow ed oroffered for ale,H y vemr,videdthatsuch
improvements ithiIntendneyearfcampleclon Il,howeveyilder Eli havengor / / TOTAL:
Improvement Lssold within oncyearolcompletlorythe ownervbullderwlll have '
tj!yd'nof proving that he did not bund or improve for purpose of sale.). QTy.77 ' 'PLUIVIBINGPERMIT,,'' .FEE., FLOOD ZONE APN
LUJ I, s owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 7064,Business and Professions Cade PERMIT ISSUANCE .
The Contractor'.License law does not apply to an owner of property who ALTERDRAINkVFM-
Wiltls or improves thereon,and who contracts for such pr -
ojects with a WATERS
y�(Iactor(s)ticenxd pursuant to the Contractor's License Law. - - FEE,•SUMMARY,
FIJI am exempt under Sea B k P C for this reason BACKFLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY If N
• Ow r Date RFGOPI'M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y— N_
I hereby affirmorkem that I have o certificate of consent d pythemo ora RECEIPT N
certificate o(Workeri Compeneatlon lrsurance ora certified copy thereo((Sec.
3800,lab CJ GAS BA.SYSHM—1 INCAOUTLETS PARKFE'E Y-- N
Polity M GAS EA.SYSTEM-OVER d(EAI RECEIPT N
Com any BUILDING DIVISION FEES
Certified copy V hereby te CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCertifled copy V tiled withh the city
e city Inspection division. -
.CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WFT 'Date ReCi t#
'(TFlssectbn need nM be completed Rthe permit b fw one hundretl dollars
(5100)pr lex.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued, —
I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TRGTING
Worker'Compensation laws of California. Date PAID
0 Z Applicant - -
NEWRESIDENTIALpLMB. jrE Date Recei t#
Z O NOTICE co esubjeAM:IL orkem'kingthb ationicateof Exemption,you c'O
FCode,shoulou=r subjcwithcoct to the Work en'Compensations orchions of s permit s Lab be TOTAL
� W deemed you=at hwith comply with such provisions or this pertN[shallbe BUILDING FEE Qd
j deemed revoked, � -
W 'CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyaf@-that there It a construction Undingagency for the perform TOTAL: ELECTRIC FEE
O ance ofthe work forwhichthfs permit is Wued(Sec.3097,Clv,C.)'
U Lenders Name - ,.�,.., - + . PLUMBING FEE
LL H herders Address : QTY.,•� ,� MEC_FIANICAG PERMIT,,, „ FEES' MECHANICAL FEE
O W Icertl(ythat]have readtNaapplicStlonand patethaitheaboveinfomution
Iscumd.I agree to comply with all city and county ordinances and pate 1Sws PERMRLSSUANCE FEES PAID:
} n' relating tobuilding constroction,and herebyauthomeerepresentativeso(thio
H W city to enter upon the abovementioned property for Inspection purposes. ALTER OR ADD TO MFGH.'
? (We)agree to save,Indemnify an d keep harmless the City of Cu ped Eno Date Receipt#
V agatrut llbBlties,judgments,rods and expenses which may In any way^acerae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL;
$j.d'Cfty lnco nceo(thegrantingo(thla Isco AIR HANDLING UNIT(OVER 10,000CFM7CONSTRUCTION TAX
re Applicant Co tractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC QpRE
Will the applicant or future building occupant store orY�andlehavardous HEATING UMT(TO 100,ODO BM Date RCcel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Coda Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU)
TOTAL:
Yea. �No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCEDATE
which emit hawrdous air contaminants as defined by the Bay Area Air -
QualllyManagementDistrict? - BOfLI!R-COMP OHP OR I OQO(O BTL))
4 Yea - No
have read the hazy usmMer,Se requi 25505, 5533underaChapter 6.95 of BOILER-COMP(OVER100,(X0BTU) PAW
the
ronannlaatlithealth kildin Cafe,Sections rrentlhave533and25534.,thatII I�pyll®u.d '
responWnd that iftify the occupant not e requir haves which must
be met
NEW RFSIDLNHALMECIi. SQ.Ff 1
pdorto uaneofaCehemte of o pancqulrcmentswhich must be met AUG 1_
pdor to Lxuance ofa CertiOcate of Ocovpanry;
Owner or aulhorimd agent Date
TOTAL: ISSUEDMM'S-
Y19Fa �
f OFFICE COPY