22277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINE GV:F CCPOINT PEN'ONL`R—, O6 .
Building Project Identification PI"IT NO.
Building Address: , 22277
G a, -�(
wn sone. A A
- a CITY OFCUPERTINO-BUILDING DIVISION
nner a Lie.No: APPLICATION /PERMIT —
-e V�ABUILDING-ELECTRICAlePLUMBING-MECIAMCAL CATEGORY CONTROL#
A neer -Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: • I PERMITISSUANCE �Z-.�9J
LICENSED CONTRACTOR'S DE LARATION ❑
I hereby affirm that l am licensed under provisions of Chapter 9(comment APPLIANCESRESIDENT.IL JOB DESCRIPTION
ingwith Section 7000 of Division3ofthe Buslnessand PrefcsionsCode,and my -
Ilcen.elsinfu or(eyrpLic. `/'-'ln PANELS ���
Limn C ss I llll or `—
Date ContractorUP TO 200AMPS
RCHITECPSDECLARATION 201-10DOA.MPSOVER10D0AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ggqwre❑l❑ ]undemtand my puns elaB remands.be used as public re '
IS O U Licensed Professloml - SIGNS ELECTRICAL ALE D
7 ¢ y OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M75C �A P V t
idA 3. Ihercb a((IrmtOWNE -BUI from DECLARATION
License 7Awfee the 'Y, i
following reason.(Section 7031.5,Business and Professions Code:Any city or
E It
O q TEMP.METER ORPOLE INSf.
�� u) muntycture rcqulreeapes Issuance,
ttomnsmquire.theaprovent forshh,orrepatr osI
3 any a pucturetatemenpriorto tshat he It alsosed pursuant to
the
provisionuch s
of the POWER DEVICES 7
file a signed statement that he t licensed pursuant it the ti oWions of the �YIRINI#
3w� Con3ofthe License Lew orfeasionscommenting ethxemp"herafon 7000)of Diel- SWIMMING POOL ELECTRICidoVALUATION
SOS the Wafthe the alleged
Any violat ation
of section here(romany
the Wah for the alleged exemption. Any ttta acivi of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
' 7s
applicant fora permit subjects the applicant to a civil pensity of mat merethan
c, five hundred dollars%5D0). NEW RESIDENTIAL ELECTR 'FT.
z.. I,as owner of the property,or my employees with wages as their sole � STORIES TYPE CONSTRUCTION
Pa mmpensation,wllldotheworiGa dthestmmm6retintendedor offeredforlr� vin
0 00
O sale&c.7044,B..Wes.nd Professlmu Code:The Contractor's Licereelaw
F$$ does not apply to an owner of property who Wilds or Improves thereon,and G S OCC.GROUP RFS.UMTS
who does Such work himself or through his own employees,provided that such s�
improvements are not intended or offered for sale.IQ howeveg the building or TOTAL:
Improvement is sold within oneyearo(completion,the owner-budder will have
the urden of proving that he did na build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FOOD ZONE APN-
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mnelruct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law doe.not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilde or improves thereon, and who contracts for such pteleeni with a
+ctor(q ssBACK PLOW PROTECT.DEVICE llcend pursuant to the Contractor's Llmss FEE SUMMARY
nLaw.
LJ I am exempt under Sec. B k P C for this reason xOUTSIDE
Ow feer Oae DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RFOmP'TN
rcby affirm that I have a certificate of consent to sal6lmarre,or FD('IURPS PER TRAP SCHOOL TAX 5Y N
rtl .a of Workers Comperuatlonlnsurance or a mAifhd mpyreo
thef(Sec. RECEIPT N
3800,Tab C') GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
RECEIPT N
Poilgp GAS EA.SYSTEM-OVER4(EA)
Com any BUILDING DI VISION FEES
Cc
copy is hereby furnished. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy IS filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.200FEr DatC Recei t#
(This section need net be completed If the permit Isfor one hundred dollars
0000)orlca..J WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the performance of the work forwhlch this permit to bound,
I shall not employ any person N any manner m as to become subject to the WATER SYSTEM/TREATING
Workera'Compensation Lawsmf Callfomia.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
_Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
Should become Subject to the Workers'Comperuation provisions o(the Labor TOTAL:
H N Code,you must forthwith comply with such provisions orthb permit shall be
ul j deemed mvoked. BUILDING '
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a lhembyaf0rmthat there h a construction lending agency for the perform- - TOTAL: ELECTRIC FEE 3.
D O anon of the work!or which this permit is issund(Sm.3097,Civ.C.)
Lender.Name PLUMBING FEE
IL I— lender•.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO Imdlfythat l have read thhapplicatlonand otatethatthe above Information
CL bcormet.l agree to complywith all city and county ordinances and state law. PFRMITISSUANCE FEES PAID:
>. relating mbulldingmvtructlon,and hereby authodae representativeaofthis
Z
etyt.reterupontheabove-mentioned propertyforlmpectlonpurpssER
o .. ALTORADDTOMECH. Date Receipt#
V e).grm to Save,indemnify an d keep harrrdess the City of Cupertino
ago net 111th,judgmenb,msroandexpenwawhlchmayinanywaya a AIR HANDLING UNIT(TO 10,010CFM) SUBTOTAL:
ago st sal Cey in c moue of the gm.tl oft Is pe
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signjuireo ApplicaR17Contractlu to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOLS MATER IALS DI SCL U E
Wllltheapplica otorfutureWildingaccvpant.mre h ndlehaurdous HEATING UNIT(M 100,000 BTU) Date Recei t#
mater.l as defined by the Cupertino Mu nlcipal Code, er 9.12 and the
Ife❑allhand Safety a thm 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant N building occupant use equlpinent or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whiahemit haaardou air contaminants as defined by the Bay Area Air - N'�kdrs•
Quality Maragemen IS ct? - BOILER-COMP OHP OR 100,0(10 BTU)
4 Yoa No 1AA
have read thele smaterials requlrements uoder Cha pter 6.95 of BOILER-COMP(OVER 100,000 BTU) UN ^ �"`^�
the 011fornia Health k Safety Code,Sections 25505,25533 and 25534. I J
unit...nd that if the build ing does not mrrcntly have a tenant,that it is my NEW REBID=- AL MECH. SQFT
nslbllitytanaifythempart of the requirements which rtws be t !tea`
dor Issuanceofa Ccrtifl f mean city,of,cum QA
OvIner or authotiend agent to TOTA ISSUED BY:MW
OFFICE COPY