22283 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a uildi.8 limiest l dentlflntirm - PERMIT NO. -
Building Address: 22283
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' kJwreF. ams: p
CITY OF CUPERTINO-BUILDING DIVISION
Co redorshianie: m. .: APPLICATION / PERMIT (�
CACATEGORY CATEGORY CONTROL p
Architect/ tines,. Lic.No: (7
41Y-- ELECTRICPE$(VIIT' �', FEE ", BUILDING,PERMIT INFO -
Address: - - PERMITISSUANCE F' p�
LICENSED CONTRACTOR'S DECLARATION,
I hereby affirm that l am Ecenaed under provisions of Chapter 9(comment APPLIANCFSRESTDENTIAL JOB DESCRIPTION
ingwith SeMon7OOD)of Divlaion3ofthe BuslnessandProfenionsCoderand my
Iiceme is in full force and effect. PANELS
License Class Lic.#
Date Contractor UvTO200AMPS Ix I iv�
ARCHITECT'S DECLARATION 201-1000 AMPS
Z I understand my plans;shall be used as public records. OVER 1000 AMPS S/SQ.FT.
CO
k t, Licensed Professional SIGNSELECTRICAL
44 6 ul OWNER-BUILDER DECLARATION `^� A i -
Tn � SPECIAL CIRCUIT/M15C / a i I
Zi_ Iherebyafflrmthat l am exempt from the Contractor's License Law for the
following reason.(Sedi.n 70315,Business and Professions Code:Any city or
O TEMP.METER Oftl'OLE]NST.
Kcoystmhmprwtois i ame,alsomuiasthemp Ucantfrsuch;arrepair
tt
any atmdedstamtethatheis;akorequ pursuant to the rovisom of tto POWER DEVICES
floe a actors License
that het licensed ening t to the pro,7000) of the
3 ec Contractors License Law(Chapter 9(commencing with Sedkn 7lNID)of Dlvl- SWIMMING POOL ELECTRIC
O soon 3 ofthe Business and Professions Cade)orthat he is exempt therefrom and VALUATION
f5'o....••336777 the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7LE155N7TCHE4FIXTURES a
applicant fora permit subjectm
sthe applicant to a civil penalty of not orethan sem+ " ipD
5� five hundred dollars%500). SQ.Fr. S W TYPE CONSIItUCTION
Cc NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees in with wages r ffelr sok
compSec.70 n,will do the Business
and rk Poand the sC dureh.Contractors
or offend for
Osak(Sec.7044,Buslnem and Profeselov Code:The Contradot's License Law _
$ does not apply to an owner of property who builds or improves thereon,and OCCIGROUP RES UNITS
who donsuchworkMmselforthrough hisownemployees,provldedthatsuch
Improvements are not intended omffered formic.If,however,the building or TOTAL:
Improvement issold withinoneyeamfcomplelion,theowner-builderwill have
tl6I,r1en of proving that he did not build or Improve for purpose ofmk) '(�Ty, /}: ]a[:UMBING PERMIT "FET;`;'' FLOOD ZONE APN
LJ as owner of the property,am exclusively contracting with Hurnsed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Cmdradore License Lw does not apply to an owner of property who -
Wilds or Improves thereon, and who contracts for such pwjeM with a ALTER-DRAIN&VENT-WATER Q?N
yy.t{{ado,(.)licensed pursuant In the Contractor's License Law. '`•FfiE'SUMMARY�
LJ I am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,CONTI. - SANITARY Y N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER],RAI' SCHOOL TAX Y_ N_
❑I here affirm that I have a certificate of consent to self-insure,ora RFOEI'T#
certificate ofW.rkeri Compensation Insurance.,a comfed copy thereof(Sce.
MOO,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy# - - RECEIPT#.
GAS EA.SYSTEM-OVER 4(EA)
' Com[any - BUILDING DIVISION FEES
Certified copy's hereby furnished, CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK"FEE
❑Cedified copy is filed with the city hapedion division. L6r
'CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP D _6
COMPENSATION INSURANCE SEWE&SAMTARY-STORM EA.200Fr. Date REtPI f#
frhia.edion need not be completed lithe permit b forone hundred dollars
($1000 or ins.) WATER HEATER W/VENT/FJ.FOTR ENERGY FEE Y 'N
I certifythat In the performance afthe work forwM1lch this permit is issued, — —
I shall not employ any person in any manner so n to become subject to the WATER SYS'T'EM/TREATING
Workers'Corepensationl,aws of California.Date PAID
O'Z Applicant NEW RES DENT AL PLMB. SQ.F. Date Recel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Workers'Comperuatlon providers ofthe Labor _ TOTAL: bT
CC N Code,you=at forthwith comply with such provislommthlspermdtshallbe U TNG . zea
W0. � deemed revoked.
c CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Z IherebyafArm that them is;a construction kndingagency,for the perfomF TOT L: ELECTRIC FEE 0
anor.f the w.rk forwhich this permit Issued(Sec.3097,Civ.C.)
O O I•endere Name ". PLUMBING FEE
ly F L ndr sAddrem QTY. MECHANICAL PERMIT iFEE'1'' MECHANICAL FEE
O W Icertllythatl havemadihkapplicatdonand&atethattheaboveinformatim
D. with and PERMIT ISSUANCE F$E$PAID:__ ,_62 -�'f-
} N relatingta building construction,and hereby authorize rcpreaentativn o(thle ��2A
(— Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date - ReceJ t#
V _ Mr)agree to save,indemnify an d keep harmless the City of Cupertino P
againstllabllltin,judgments,.A.and expenseswhlchmayinanywayaccrue AIR HANDLING UNIT(TO IO, CFM) ' SUBTOTAL:
-2-s-
ags lost said Citynspermit.
equence of the grant ing of this peit.
/coAIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Sig to of polcant/Contractor Da . EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX,PAID:
HAZARDOUS MATERIALS TSC SURE
Wllltheappbcant or future bullding occvpa st orhaMlehaxardous HEATING UNIT(TO 100,000 BTU) Date Recei t# �s'
maudialaade(Ined by the Cupertino Municipal e,Chapter9.12,and the
Health and Safety Code�+.-S� AL
Section 25532(a)? HEATING UNIT 100,000 BTU) TOT :. lit
❑ Yes 1I No
Will the applicant or future building occupant use equipirent or devices VWITLATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous ak rontarrh ants as defined by the Bay Arca Air
Quallty Management District? BOILER-COMP QHP,OR 100,000 BTU)
[?YeanNo
have read the hazardous materials requirements under Chapter6.95 of, BOILER-COMP(OVER 100,000 BTU)
the California Health&SafetyCode,Sections 25505,25533 and 25534. I JON
understand that lithe building does not emmotly have a tenant,that It is my NEW RESIDENTIAL MECH, SQ.Fr. �i.7aFL1
responsibility to notify the occupant of the requirements which at be met'
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL. ISSUEDB �`
OFFICE COPY