22465APPLICANT TO FILL IN INFORMATION WITHIN RED LINES 7—•98E4WU L -POINT PEN ONLY
Bulldin Project Identification - �L ; yp
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
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Can re Name: � m. No:
CATEGORY CON&CWOI
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BUILDINGELECTRICALPLUMBINC-MECHANICAL
QTY - ELECTRICPERMIT FEE
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BUILDING PERMIT INFO
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PERh11TIS5UANCE `�
LICENSED CONTRRATION
-
Iherebysfflrmthat lam licensed ofthe erimessaonaof Chaptaa9(rommeno-
under provisions
In ease la a full force and vblan3 olthe Budneaeand Pro(esslonsCode, and my
license lain full Torre and mlect. i'
Licenea Claes ' LIC.p
AlaIsLIANCESRESIDENTIAL
10 DESCRIPIION -
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PANELS
Date Conlmdor
-/�
201-11DOAMPS
ARCHITECPS DECLARATION
•l understand my plana dull be used as public record&
OVER IOW AMPS
SQ.. FT`. FLOOR AREA
Fr.
SIGNS ELECTRICAL
Licensed Professional'
�/ (�S'j�1/A
1 �`.•VV rp
^$/SQ.
9 SQL'
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OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt fromthe Contractor's Llcenae Law for the
following reason. (Section 7031.5, Business and Pmfenions Code: My elty or
county which requires a permit to corabum, alter, Improve, demolish, or mpmr
any stmctum prior to Its Issuance, also requires the applicant for such permit to
file a dgne! statement that he is Icemed pursuant to the provisions of the'
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3ofthe Buslneae and Professions Code) orthat he is exempt therefemand
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit subpRstheapplicant to a civil penalty of not more than
flur �hundred dollars ($500).
u 1, as owner a! the property, or my employees with wages as their sole
SPECULCIXCUIT/MISC
�yP.METFROR POLE IN
POWER DEVICES
PATE
`'Ews
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'M1Sl
SW04NENG IDOL ELE C-
OUTLETSSWTTCHES-FIXTIIRES
_ter_ ALUATION_rss}
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'L VJyJ 1 1.(i I .
STORIES
NEW RESIDENTIAL ELEGTR_SQ.FT.
2
compensation, will dolhe work andthe structure Isom Intended or olferecifor
sale (Soe.7000, Business and Profeeslons Code: The Contractors License Law
0
-
- - -
doesnot apply toanowner ofproperty who Wilds orimproves thereon,and'
who doessuchwork hlmselforthrough hlsownemployees, provided thalsuch
GROUP
RES. UNIT .
improvements us, not Intended m6fferedforsale. If, however, thebullding or
,theowner-builderwlllhave
1 TImprovementIssoldwithinoneyearofcomplmb
4Q.louden of proving that he did nm Wild or Improve for purpose ofule.).
LJ L ss owner tr the property, am exdu Busi essand ing with licensed
to eanetr Project (See Blaeiness and
Code:The
QTY,PLUMBING PERMIT'
PERMIT ISSUANCEThe
D ZONEconAPN
Cman .the
of propms
apps70K
Coor Impro es the law don rat apply tct en owner m Property who
or Improves thereon, and wed mrrcracta ice seeL projema whh a
0151 m(aexem t Pursuant to she Contactor'. Llmnx law.
am exampl under See. B & P C for thio maven
,UTgg-DRAIN & VENT- WATER (EA)Woes
FEE SUMMARY
BACK FLOW PROTECT. DEVICE.LII
Q1 ITqI I)V RT.
DRAINS FLOOR ROOF, AREA, COND.Y
I
Y N_RECEIPT aWORK
Owner Date
MAN COMPENSATION DECLARATION
hereby f have nMRaate to
FO(7URFS PER TRA
TAX Y_ N❑mdlfl
ofilers Cm of convent op thereof ora
o
Lab of Work<n'Compewtlonlmurance on certified ropy lM1ereof(Sm.
Lab C.)PWIry
RECEIPT3800,
GAS EA. SYSTEM -1 INCA OUTLETS
Y NBalk,
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GAS EA. SYSTT4.OVER O (G)DING
Cam ny -
BUILDING DI VISION FEBS
DI
�CertlOed ropyIs hereby fumlehed..
Certl(Ied ropyIsfiled withthe city lnspecHan division. CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDU5IRL WASTEINTERCEPTORI-IGCK�:
e1341 C,�C1, t32
�8
GREASE TRAP
COMPENSATION INSURANCE
(0) .r lAmion need not be completed tithe permit b for hundred dollars
(Sl certify that
I certify that o the person in e of any he rearrer fors to b coo permit b booed,
I shall not employ any parwn in any manner su n to become suh)cct to the
Workers'Compensation Lawsof Cahfornb. Date
Date RCCCI I#
SEWER -SANITARY -STORM EA. 2WFF.
WATER HEATER W/VENT/EIECTR
ENERGY FEE P joi��
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PAID'` 1
ICO, Cb
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions, orthb permit shall be
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deemed rev
CONSTRUCTION LENDING AGENCY
Date Recd f#
NEW RESIDENTIAL PLMB. SQXT.
yt�
5 _
TOTAal
Uoked. L DING FEE I -0
3 3 7' u
SEISMIC FEE r '%1- -.flOr
- -
I herebyaNrmthat there Is a construction lendingagenq forthe performTO
ance of the work for which this permit Is Issued (See 3097, Civ. CJ
_
—
ELECTRIC FEE
LendaraNams
Iendereaddreas
Trued. tagreet comply with allcitland cuntyandirances elm state law.
aeroingtobgrn to complywo,andharedcouhorize nanmsa
QTY. "MECHANICAL PERMIT FEE
PLUMBING FEE _
MECHAINICALPEB L-601
I. PERMTTISSUANCE I ��
FEES PAID:
timatelawe
colon, and hereby authorize repressnpu rposo(thb
relating to building a above-mentioned
'oilyW)aree to themnfyipropertyforbupe Cit purposes. CT)acs.
(We) agree to cava, Indemnity do d keep harmless the City o! Cupertino
against llabilltlee,jidgments,et
ms end expenses which may In meany eye c
It
Date RCCCIPt#
- SUBTO
ALTER OR ADDTOMECH.
AIR HANDLING UNIT (170 IO,OW CFM)
IRHANDLING UNIT (OVER IO,WDCFM)
_
CONSTRUCTION TAX
,
Signammca!''
HAZARDOUS MATERIALS DISCL
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TA $�
HEATING UNIT(TO IW,ODO BTT)
Wllllheappli.et or future building occupant store or handle hazardous
nuterbla,dcfincdbythe Cupertino MuNdpal Code,Chapter9.lZandthe
Date RLtiei t#
HEATING UNIT (OVER 100,O00 BTU)
Health and Safety Cade Section 25532(a)7
DY., r`] No
VEMTIATION FAN (SINGLE RESID)
`ISSUA^NC/ED TE
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Will the pplicant or future building occupant use equipment or devices
which emit hag rdow air mntaminantsae deBmM bythe Bay Area Air
alit Mara emend Matrict2
Y. (-1 No
4
BOILER-COMPOIIPORIW,0MBT UI
BOILER -COMP (OVER 100,0W BTU)
PA
have read the hazardous mtenals requirement, under Chapter 6.95 of
the Cilifornb I IMth&Safety Code, Sectors, 25505,25533 and 25530. 1
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NEWRESIDFNTIALMECH. SQ.FT.
undemmmd that if the building does not currently have a tenant, that It is my
nspon ibllity to notify the occupant of the requirements which must be mart
prior to Issuance o/e Certificate of Occupancy.
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ISSUED B�It%„ b
Owner or authorized agent Data
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OFFICE COPY
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