22100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address: 22100
Ile
nersAPPLICA IION SURRITTAr=
ante CITY OF CUPERTINO-BUILDING DIVISION �I�r a
coma. or'. ant: m.Na: APPLICATION /PERMIT h L
BUY,DINGELECTRICAL-PLUMBING-MLCHANICAL CATEGORY CONTROL X
A ItM/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECI PLUMB Mi�hi
Address: PERMITISSUANCE [I ❑ o
LICENSED CONTRACTOR'S DECLARATION
Ihereby
that l ann
IcHeensext under provisions Cha 9(comc
APPOAN
CESRESIDENTIAL ]OB DESCRIPTION
Ing with Section7").f Division Business and Profession.Codeand my
lcenmislnfuBfameandffect— PANELS
CWs "VLimner
DateContrmt.r� LIP IQ 20EAMPS
ARCHITECTS DECLARATION NI-1000 AMPS
oto 7 I understand my plam shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
K ly o LicensedProtesslonal SIGNS ELECTRICAL
<Q� A
OWNER-BUILDER DECLARATION FA CIRCUIT/MISC
t, z Iherebyafftrn that I am exempt from the Contractor's License Law for the
Q)t- following reason.(Section 70315,Business and Professions Code:Any city or TpTpM METER OR POLE INST.
7 county which requlrcna permit roconstruct,alter,improve,demolish,earepalr
PM9.QI anystmci mpnortoitsisaaam� aL mquimstheappBantforsuchpermit to
K�V file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3
Orel Contractor's License Law(Chapur9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC 0 sion3ofthe Business and Professloru Code)orthat he W exempt lherefromand VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFY(TLIHES
iCCa.:)
applicant fora permit subjects the applicant to a civil penalty of not mom than
five hundred dollars L%5(10). NEW RESIDENTIAL ELECTR SQFI. STORIES TYPECONSIRUCTION
.. n 1,as owner of the property,or my employees with wages as their sole
compensation,will d o the work and the structure is not intended or offered for
Osale(See.7044,Business and Professions Code:The Contractor's Liceme Law
S� does not apply to an owner ofproperty who Wilds or Improves thereat,and OCC GROUT' RES.UNITSwho does such work himself or through his own employees,provided that such
Improvements are not Intended oroffereel for sale.If,however,the Wild Ing ear TOTAL:
Improvement W sold within one year of completion,the owner-builderwlll have
try..karden of proving that he did not Wild or improve for pu rpose,of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMETISSUANCE ,.ate
contractors to coasmIct the project 4,(Sec.7MBusiness and Professiom Code: C
The Contractor's License Law does not apply to an owner of property,who ALTER-DRAIN&VEM-WATER(FA)
Wilds or improves thereon,and who contracts for such projMa with a
obactor(s)Barnard pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
DRAINS.FLOOR ROOF,AREA,CON I. SANITARY Y_ N_
• Owner Date RECEIPT X
WORK MAN COMPENSATION DECLARATION FIXTURES PER TR/aP SCHOOL TAX Y_ N_
21 hereby affirm that I have a certitWte of consent to self-insure,ora RECEIPT X
11 icate of WmImra'C.peswtlonlssur...ma certified copy thereof(Sce. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Tab C. —
PmlryX 171 V7D0��-1. rX
Cu
GAS EA.SYSTEM-0OVER BUILDINGDING Of VISION FEES
CMmed copy v hereby furnished. PLANCHECK FEE
Certified copy Wfiled with the city lmapection divlaon. CREASE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF UOY!PFION FROM WOR KERB' GREASE TRAP �yy PAID
- COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 200F1' {J Date Recei t#
(rhissection need not W completed If the permit later arm hundred dollars($100)orle sJ WATERHEATFRW/VENT/ELECTR 'NERCY FEE Y_ N_
I certify that o the performance of thework fo as to l this permit a Wauod, z
I shall not employ any pesmn In any manner m as to become subjM to the WATER SYSTEM/TREATING
workers Compensation Larva o(CaB(omW.Date PAID
OZ PPL
Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei tic
Z O NOTICE TO AICANT:!!,after making this Certificate of Eiemption,you
should became subject to the Workers'Comper cation provisions of the Labor TOTAL:
F N Code,you must forthwith complywith such provisions orchis permit shall be BUILDING
W ] Beamed ree.kad.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 G Ihereby afftrmthzt there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
� Z ante of the work for which this permit W bsued(sec.3097,Civ.C.) a PLUMBING FEE
V O lender'sName
fql
LL I— Lender'.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Imni(ythat l have read thbapplicationand state that theabove information
0 W
1 bcorrM.l agree to comply with all rityand county ordlnanms and state laws PERMIT ISSUANCE FEES PAID:
>. relati ng to building construction,and hereby authorize representative.ofthis
W it t entero upon above-mentioned ro forW ion ALTERORAODTOMECH.
H Z rya ro P Pert)' The Purposes. Date Receipt#
_ (We)agree to trove ' emnify aade= artch essthe City of ywaacemetim AIR HANDLING UNIT(TO 10,000 CFM)
agaWtllabWBn,p meals,cosh and ex sn which may In anywayaccrue SUBTOTAL:
Ny
dCI cororefemoofthegr un this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
o II n/ ontracto Date E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUREe applicant orfutumbullding amspant store or handle hazardous HEATING UNHOO IDgfAO BTU) Date Reeel t#
rest rWl as drflnad bythe Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety CoolieSection 25532(a)? HEATING UNIT(OVER 100,0W BTU) TOTAL:
No
-1 YesenIhL
pplkant ha rebuilding occupantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit barardous air contaminants as dented by the Bay Area At, �.9
.
Quality Management District? BOILER-COMP QHPOR 100,ND BTU)
4Yes R71 No
havercahdthebazas�ihusmaterialsrequlrementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) �� Q u 199
the California ealth&SafetyCode,Sectlons 25505,25533 and 25534.I J
understand that if the Wilding does not currently have.tenancy that it is my NEW RESIDENTIAL MECH. SQ.FT.
respomaibility to notify the occupant of the mquirements which must be met
P,
toissuanceof Ceriili tro Omqcp.m�y. (shy�' GSAL}1E G
er car authorized agent r 1 `�ate TOTAL: ISSUED BY:
OFFICE COPY