22976 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL P INT PEN ONLY
Bulldln Ymat Identification PERMIT NO.
Building Address:
oars �1E�S c�avo� LSD . - 22976 '
nems ante: - one:
5 Co13Ac2UV IA-L- g411, °�OS'Z- CITY OF CUPERTI O- L• G IVISION ��1 I
Co.tractor's Name: ll ( LIc.Na. qpp LICA P MIT L �
I• I ( '[-1 OIJ •1I WL-RS 'AIL s 6 O I SZ- BUILbINC-ELECTRICAL BI -MECIIAMCAL CATEGORY CO
Arrhllect/Engineer. - Lic.No:
G. 14�L LD v QTY �E IC MIT FEE BUILDING PERMIT INFO
Add...Ib M 57IB0 O�- A_7Iy I
I'FRM1BTISSU CE
LICENSED CONTRACTOR'S DECLARATION
Thereby alflrmthat l amlicenaed under provislansof Chapler9(comrs A CES.RES1 NTUL Roo rrsnD '
Ingwlth Seedon7000)of DlWsion3ofthe Bualnessand ProfessionsCAde,and M/�R"
license is In(uB mm and effect / C)I`✓Z� S.—. 6-0
s
Lice. Clam Llcp v0 as^ .•Vs
to Cmux dorTATGO v
ARCHITECTS DECLARATION 301-1000 I'S
mOZC Iundentand my pine.hall W used as public records OVER DAMPS SQ.FT.FLOOR AREA S/SQ.PT.
�u Lirensed Professional 51 SELECTRICAL 1�/��.. q'�/�
OWNEReBUILDER DECLARATION IAL CIRCUIT/MISC �,•+�_w`
7F, Ihnreby affirm that I exempt ER the Contractors Licenselaw(or,he L 111�"TIIITTIII GJ
(°sowing reason.(Section 70315,Business and Profemkma Code:Any dty or
$ p Q coon whichrc 1 Permit tocoatad,alter, edemrolish,orrepalr TWiP.MEITR ORIOLE INST. `-
ry quresape prow, O Qy�
7 any alrutlure
lta Issuance,also reh permit toPOWER DEVICES a signed statement that he is licensed pursuant to the provela of the
µ Contractor's ceracLa (Chapter 9(commencing with Section 7000)of Divi- SWE7MINGPOOL
ELECT0sl..3.ftheBusincesa.diPreemlouCode)or[hathebWC
o
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLE7SSWITCHEShTXTURES �1 SO �1 Z�
applicant fora permit subjects the applicant to a civil penalty of not more than l�
five hundred dollars(S501)). NEWRESIDENTIALELECTR SQFT.
�n I,as owner of the property,or my employees with wages as their wto STOW TYPE CONSTRUCTION
compensation,will doth work and thestructure is not Intended or offered for
i q sale(Sec 70K Business and Profession Code:The Contractors Lt..Lw
does not apply to an owner of property who builds or improves thereon,and R 5 '
who deconceh workMmxlf edorofgredfar ale,if owever videdtheb ildingch u V 0
Improvementsarenotintended°cofferedforole,thecemer- deer ill have L
Improvement issold within ane yearofcampldlon,the owner-bugderwBl have
t ben ofproving tht he did net build or improve for purpose of sale.), QTY. PLUMBING PER �AT
EL1,ae owner of the property,am exclusively contracting with limned PERMIT ISSUANCEcentracton to coretruct the prefect(See.7044,Buai..and Perfevloa Code:The Contractors License Lw does not apply to an owner of property who ALTER-0RAIN k VENT-WATER(EA)Wilda or Improves thereon,and who contnda far such ptp*U with a FEE SUMMARY
b,1Bfactor(O licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for this...
Owner Date DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N_
RECEiPI p
WORKMAN COMPENSATION DECLARATION 'PER TRAP SCHOOL TAX Y— N
❑I hereby affirm that I have a certificate of consent to mlfdnsere,or a
mrtlfimteofWorkers'Compewtlonlreuunmoramrtifkdcopythennf(Sec. / RECEE'f N 3800,Fab C.) CAS EA.SYSTEM-1 WC.40U3LEI5 !� PARK FEEY - N
l
Polity p GAS EA.SYSTEM-OVER 4(FA) RI NC DI p
Co nY r BUILDING DIVISION FF.ES
ertified copy is hereby furnished. CREASE/INDUSTAL WASTE INTERCEPTOR PLAN—CHECK FEE
Certified copy is filed with the city Inspection division. 1�
CERTIFICATE OF FAEMPTION FROM WORKERS' GREASETRAP PAIIJIJ�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 3WF1• Date RC 1 �. l"•'
(TWlaanctlon need not h completes If the permit is(or one hundred dollar
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ceni(ythat in the performance of thework forwhleh this permit Is Issued, —
1 shall not employ any person In any manner so ea to become subject to the WATER SYSTEM/TREATING ,
Workeri Compensation,Taweof Callfomis. Date PAID
OZ Applicant Date Recei t#
CC
Z U NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFf.
should become subject to the Worknn'Compensation provisions of the Labor TOTAL:
fed
LU Cade,you It forthwith comply with such provisions orthis permit&hall be l
j deeed revoked.
IN
LU
mG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a firm that there isa matructlon tendingagenry forthe perform ELECTRIC FEE
Z. anceaftheworkforwhlchthiaperMtlalasued(Sec.3097,Clv.C.) TOTAL:
02 hnaer'.NamPLUMBING FEE
t
ly F ender's Add ass QTY. MECHANICAL PERMIT FEE MECHANICAL FEE �—
W Iscoirgt l tlldmgcomplymatnewith andtyand auntyizerep arnoti etatelaws PERMIT ISSUANCE
�� FEE$PAID:
} a relat oenterupont eabsection,andhreby operty a looppresenpurpoa of this
Z city to area to save,
indemnify
d propertylor Wpe Cit of Cupertino
ALTER OR ADDTO MECH. �s Date Recci t#
V — (We)agree is nave,Indemnify and keep harmless the City y Cupertino
age lest Baid(Zies dgmeuencecosts and expenses which rayl.enywayaccme AIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL:
agaWbaitl Ci mnaequence the granting of this permit.
1 a0 _ AIR HANDLING UNIT(OVER t0,IX10CIM) CONSTRUCTION TAX
IA.sl rcof pp icant/Co ra or —J Date IXFIAUST HODD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR ON MATERIALS DISCLOSURE
Will the applicant or m building omrpant store or handle hazardous HEATING UMT(TO I00,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
1 lea It h and Safety Cade S din 2M2(a)i HEATING UNIT(OVER 100,000 BTU) TO
I—I Yea No
Ill the applies.,or Nrebuilding occupant use equipment or devices VIN'ILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous air coDistrict? minants..defined by the Bay Area Air W
Quality Management District? BOILER-COMP(3}1r OR 100,000 BTU)
'I?I Yrs ( o.No
.
have read the h aza ous matndars requirements under Cha pter 6.95 of BOILER-COMP(OVER 100,000 BIIf) �
the Gltandt Health building
Code,Sections25505,25533have
ate ntl,that I A /'� O
underesponsibility
to if notify the rcupara of
a requiyhaves which
that b mets my NEW RESIDENTIAL MECH. S'Q.Fi. b�3�k
respoaibiiity to notify the occupant of the mequlrcmrente which must be rant i � -
prior to issuance of a Certificate of Occupa ney. vaJTkii-/.
rl iI/I/l/
Owner or authorized agent mt. ISSUED BY<•^-'y""�.'I
OFFICE COPY �'