22603 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentmcationI ^ 10PMWT NO.
Building Address: Lu J, � L L� 22603
nor N ame: one: - APPLICATION SUBMI11 AL DATE
CITY OF CUPERTINO-BUILDING DIVISION
ontrznors Name: Lie.No: APPLICATION /PERMIT
141WIArchite0 glneer. - LIe.No: BUILDING-IB,ECTRICALPLUMBING- ECHA AL CATEGORY 1 41
CON=
ct/EnQTY ELECTRIC MIT PEE BUILDING PERMIT INFO
FLUME —VM*rr—
ziddms,: PERMITISSUAN 2 ® A
LICENSED CONTRACTOR'S DECLARATION ,
T hereby.effben that l am licensed under provhlanso(Chapwrl)(commec APPLIAN DENTIAL 10B DESCRIITION
Ingwith Sed1on7000)ol Div sion3ofthe Busimmand ProfessionsCode,and my
license Is in s force and ellen. PA / �
LicenseCh® LLCM `\7
Date Contnnor Q 200 AMPS
ARCHITECT'S DECLARATION 1-1000 AMPS
Wp qzq ]understand my plarashall be used a a public records. OVERI()(p AMPS SQ.IT.FLOOR��AT.R�EA $/SQ.FT,
V(0 Licensed Professional SIGNS ELECTRICAL
/d Wyka1�l OWNER-BUILDER DECLARATION SPEC1ALCIRC / 8 TJ
Z IC'-�'" I herebyalfirmthat l am exempt from the Contradole License law lee the OG &�
po following reason.(5ocdon 70115,Business and Prefcolons Code:Any my or
Fztpppp"�ggqqu�u�?y county which requires a permit tocomtmct,alter,improve,demolhh,orrepalr 'IT•MP.M
p U anystructure priori.it.issuance,aho requires theapplicam lorsuch permit to
POWER DEVICES '•'✓ B-
U flk a signed statement that he Is licensed pursuant to the provisions of the
w Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi.
{{..�OS sion3ofthe Busressand Profemlom Code)orthathehemmptthemfmmand NG PooD�E'cSR1C O L VALUATION/r,
sd < the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLFTSSWITCHESFIXTURES T!� C•••3 q yet a v0
I�
applimot fora permit subjectsthe applicant to a civil penalty of not more than ✓' J✓ L v
6 live hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.Fr.
ML as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
7 compensation,will clothe work and thestmcture is not Intended or offered for Q r D
O asle(Sec.7(R4.Business and Prolessiov Code:The Contractors License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUIa RES.IONCI5
EE: who doeasuchwork binalf
eorthwgh hisownemployees,provided thatsuch 1 �
Improvements are not Intended proffered for ale.If,however,thebullding ur TOTAL
Improvement issold wilhinoneyearofcompiniomtheowner-W Ilderwill have
rdenolproving thatheped not Wlld or improve for purpose ofsale.). QTY, PLUMBING PERMIT PEE FLOODTVNE APN
as owner of the property,am exclusively contracting with licensed pppp ISSUANCE
tractorstrod the projed(Sec 7014 Business and Professions Code:
e Co MK
Licen doe,not apply to an owner of property who ALTER-DRAIN k VENC-WATER(EA)
WE or Ia errors, d who contracts foe such-ptojens with a �•'–
noRnyuan t thaC tractor's LicenseLaw. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
I am er B k P forth reawn
t DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y— N—
DaOUTSIDE FE
te RECEIPT
N
WO KMAN COM SATION DECLARA N FIXTURES PER TRAP SCI{OOL TAX Y .N
❑1 hereby affl.that I hav a o nifiate al consent to self-Insure,or RECEDT N
certificate ofWorknn'Compereation lmurance ora certifled copy thereof eim, GAS EA.SYSTEM-t INCA PARK
3800,Tab C.) IEE Y— N
Policy Y GAS EA.SYSTEM-OVER 4(EA) UI NG Of
N
Com any BUILDING DI VISION FEES
ffCertlfied copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
MCedifled copy h filed with the city impedion division. Qr
CGRTIFIGMPE EXEMPTION GREASE TRAP PAID_______,? S�
COMPENSATION INSURANCE SEWER-SANTTARY-STORMEA.200FT. DatC R 1 t#
(Thio section need not be completed lithe permit h(Drone hundred dollen
($l0D)orla®.) WATER HEATERW/VENT/ELECTR E Y
I cent that In theperson
performance any
he manner
so an to b co eese bjecit 1.Issued, —
I shall not employ an/pereon In any manner eo u to become wbjen to the WATER SYSTEM/TREATING *7
Workere'Compensatlon Laws of California.Date - PA bl
O Z Z_
NOTICApplicaE
- NEW RESIDENTIAL PLMB.__SQ.FC. Qat,. ecel t#
Z O NOTICE co e,subiCttothe cul makinm en Certificate inionsof the Labor
Code,shoulyou
must forth ith co Workers'such prvide .,thin permit
s Lab be T TAL:
� N dremedre must forthwith comply with each provhlom orlhh permit shall be UI G
y deer d revoked.
W CONSTRUCTION LENDING AGENCY SEISM IC FEE
d Thereby a(Urtn that thea h a construction lending agency for the penorrtr TOTAL. 1y^'Y.l ELEC'1•RIC FEE
"list
Z ance ofthe workfor which this permitia beard(&c.3097,CIv,CJ –` (v
V O Lender's Name PLUMBING FEE
U. h- Lenders Add QTY. MECHANICAL PERMIT FEE MECFIANICAL FEE Q
OW Icenityt hav rcadthh appllallon end nate lhattheabove infomutlon
1 hrormn. greeto omplywlth all city rountyardlnances and state laws PERMIT ISSUANCE FEES PAID:
>. 0.
relating bmldln omtmnlen,end hereby authorlu representatives ofthh
Z �ry
to tarupon abeveemntloed property for Inspection purpose. ALTER OR ADD TO MECH.
agree t ve,inde n d keep harmless the City of Cupertino Date eceipt#
L) ar tllabllitl judgme t,ectin. expenseswhleh vayln anyway AIR HANDLING UNIT(TO 10,000 CFM) $UB OTAL: o
ai tram 1 e o t granting of this permit AIR HANDLING UNIT(OVER lB0D0CFM) CONSTRUCTION X Z!1
eL
se
SI tar ppliant/Contractor k EXHAUST HOOD(W/DUCT) :C:O:NSTtRUCTIONTPAID:
HAZARDOUSMA 'RIALSDISCLOSUREWill theappllant or future bildin onupantmreor handle hazardous HEATINGUNIT(TO10D,ODOBTU) Dae Rec i t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TO 1
❑Yes No
WRltheappllant orfutureWildingomrpantuseequipment ordevicen VMIMLATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Illy Management DlsMn7 BOILER-COMP OtIP OR l00,IXq BTU) P A D
Yea nO No
a Mver earthhe Safety
materials rcons 255 5,2553underChapter
and25534. 1 of BOILER-COMP(OVER 100,000BN)
the Californiaia Health k Safety Code,Sections 25505,have
a tenant,and 25534. I 21 1991
respunderstandthat lithe nmtfy the ocgdoe ern erequire encs whichthat It met NEW RPSIDENTfAL METH. SQ.FT ND\I
rvpomlbliity to nnlfy the occupant of the requirements which must be met Y
prior to issuance of a Certificate of Occupancy. Oily Ur CuptN I INU
Owner or authorized agent Dat '7 eISSUEU BY:TOTAL: 1"a
OFFICE COPY