22332 "APPLICANT TO FILL IN INFORMATIO WITHIN REDLINES — USE LL POINT PEN ONLY
Building Addreas:Ildl�Pro ed ldentllcallorr ;Zx;2 / / m-tea^ PERMIT NO.
:7-7 v^Poul 22332
e aces: one: A
—708(/ CITYOF CUPERTINO-BUILDING DIVISION
C acts °Name: LITT.Ne: APPLICATION /PERMIT
S.9SPJS BLULDINC-ELECTRICAL-PLUMBINC.MECHAMCAL CATEGORY CONTROL
Architect/Engineer: LIc.No:
QTY ELECTRIC PERMIT 'FEE BUILDING PERMIT INFO,
Addmes: PERNUTISSUANCE ❑ ❑ x�/I ❑
LICENSED CONTRACTOR'S DECLARATION
Ihercby affirm that l armlicensedoftheerp Business and
sofChapter9(comment PANELSAPPL1ACESRESIDENTIAL JOBD RII'FION _
Ingwith Section 7000)of DlvlYan3oftheBusinessand ProlesUonaCode,asci my - - � L`��, (f,/J-(�/�T-
BccnselslnfoR ortx and dlM. PANELS /`
License Clam = Ccs�Sa 11 /�
Date�— ConlraRor_S /(.tom--.� W
_
ARCHITECTS DECLARATION NILIOOOAMPS '
+q�+00G I understand myplzvahall be used w public records. OVER IOW AMPS SQ.FT. AREA $/SQ.FT.
bof Licensed Professional - SIGNSELECTRICAL'
6 OWNER-GUILDER DECLARATION SI'FCIALCRCUIT/MISC
7 "7 1 hcrebyafflrmthal l am exempt fromthe Contractor's Llmma Lawfortha
qqqq following reason:(Section 7031.5,BuYncs and Profeenions Code:Any dtyor
0 countywhlchrequimaapermlttommtmmalteplmpmve,de=Hsh,orrepair TEMP.METER OR POLE INST.
q'� a anystiuctum prior to its bsuanee,alsomquims theappllcant forsuch permit to
file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES t
CmInictorbLicense Uv,(Chapter9(commencingwith Section 7000)ofDisk SWIMINGPOOLELECTRIC I VALUATION
ti�Os sion3 of the BuYnessand Pro(essiovCom)orthat he b exempt therefromand -
the basis for the alleged exemption. Any violation of Section 71115 by any
G5
applicant for.permilsubjectstheapplicanitoa civil penaltyof not morcthan OUTLETSSWITCHES-FIXTURES
five hundred dollars($.A0). NEWRFMDENTIALELECTR SQ.FT. SfOWIS TYPE CONSTRUCTION
(il �n ❑L as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not Intended or offered for
QssIs&c.7044,Busivsaand Prdessiov Code:The Contractors License law
jB does not apply to an owner of property who Wilds or improves thereon,and - OCC.CROl1P RES.UNITS
whodocsauchworkhi.lf.,through hisown employees,provided that ouch
Improvements arc not Intended or offered for Bale.If,h°wever,the building or TOTAL: -
Improvement b sold within oneycaro(completlon,the owner-bullderwill have
t"rden of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT ,FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed pp IT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: ,Q
The Contradorb License Law don nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) '
Wild. or I.E.thereon, and who contracts for such pSojeas with a FEE SUMMARY
cNRlpdor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B&P C for this reason
OUTSIDE FE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N- -
• Owner - Dale RECEIPT#
WORK MAN COMPENSATION DECLARATION FLXTITRF-.PER TRAP SCHOOL TAX Y N_
�1 hereby orke that I have o alit rate of consent to opytheure,ora RFCE"Y
certl teats ofWorkem'Compensa/1onlvurance ora certified copythemof(Sec. CAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N—
N
C. RECEIPT#
Policy pJd[�.U'4,DO6af, —I GAS.EA.SYSTEM-OVER Com aenf,(c. is h36_ ` d BUILDING DIVISION FEES
Certified copy b herebyth thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
'
Certified copy Is filed with the city Inspection division:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP '" PAID
rubeuCOMPENSATION INSURANCE SEWER-SANITARY-SFORM EA.200FT. Date Recei [#
(T)re Im ion need net W completed II the permit b(Dross hundred dollars
($1I unify that
WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
I unify out that in she pedo on in anyof mannerhe w sat to becamh this e
permit b bored,
N—
],hall not employ any person In any manner a u to berome eubjm to the WAT R SYSITM/TREATING
Workers Compensation Laws of California. Data PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
Z O NOTICE TO APPLICANT:](,after making this Certificate of Exemption,you
should become subject to the Worke'n'Compevatlon provisions of the Labor - _ TOTAL:
W Code,you must forthwith comply with such provisions or thin permit shall be - -
W > deemed revoked. i BUILDING
d c CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there b a construdlon lending agency for the pr fta ry ELECTRIC FEE
Z ante of the work for which this permR is issued(Sec.3097,Civ.C.) TOTAL: a
V O' tenders Name PLUMBING FEE -0D
1L F Lcnderb Addreas Q7Y, MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertllythatlhavereaithbapph tionand ist.what the abovelnformatlon
1 bcormd.Iagreeto complywlth all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorlre representatives of this -
Zcity to enter u pan the abovcmentioned property for Inspection purposes. ALTER OR ADD TO MUCH. Dale Revel f#
V _ (We)agree to save,indemnify keep(y an harmless the City of Cupertino P
against liabilities,,dgmente,cress.rd expenses which may in any way accme NR HANDLING UNIT(TO I O,WO GEM) SUBTOTAL:
against said City In mvequence of the granting of this permit.
t AIR HA NDLINGUNIT(OVER 10,000 Cr•M) - CONSTRUCTION TAX
Signature of Applicant/Contractor i Date ,,, _ EXHAUST HOOD(W/DUCT) �' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 10occupant0,000 BTU)
meterialas defined by the Cupertino Municipal Code,Chapter 9.IZ and the _ Date RO°el [#
I leahh and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: �(/V
❑ Yea ,[may No '
Will the applicant ob(unam Wilding occupant use equlpment or devices VENTILATION FAN(SINGLE RFSID) - - ISSUANCE DATE
which emit harurdous ab contaminants as defined by the Bay Area Air s.
. Quality Management Dfstrictt - 30I1,ER-COMPi3HPOR100,00I8TlA ' �a1VD
Yes No
havereadthebus us materfab rtquimmenit under Cha per 6.95 of BOILER-COMP(OVER100,000 BTU) ��� K �QQ�
the California Health&Safety Code,Sections 25505,75533 and 25534. I V
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.p-L
respoviblllty to notify the occupant of the requirements which must be met _
pr lo_lssuanmcfa Cedif am olocccapanry-. y oft
Veorauthorlmd agent Date
TOTAL: ISSUEDBY:
OFFICE COPY