22531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: - 22531
con re ams: one: p
[� CITY OF CUPERTINO�BU ILDING DIVISION
at°r'°"a^rLic," APPLICATION /PERMIT
• C BUILDING-ELECTRICALPLUMBING-MECEIANTCAL CATEGORY CONTROL N
rchltect/Fnglmer. Lk.No:
CITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
the affirm that l am Bernard under provisions of Chapter9(mmmm APPIdANCESRE5R7ENMl JOB DFSCRfI'7'ION
ingwllh5 olon700D)ofDlvlelon3ofthe Businemand ProlessimeCode,and my �••Y-� � �
it...is In full force and effect. PANELS Two p>rlq—w
Licaracclam Lk.If
DaleContrator P-6i t 0 Fr-L
ARCHITECTS DECLARATION 201-1000 AMPS
�p+9O Zp Lunderslundmyplamahall beuxdaspubberemrds. OVERIUOOAMPS �r
&% Licensed Professional SIGNSELECTRICAL
1
<<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC - 1 1 1, YJ T E R
7p [� affirm that hereby affirthat l am exempt from the Contractor's License law for the \�' ,]a Y77
op ❑❑❑❑ following reason.(Section 7031.5,Business and Professions Code:Any city or a1 i Q
�Z�ty cmntywhichrequiresapermltmmmtmcgalteglmpmvgdemolbh,ormpalr �Mp'MEIT9(OAPOLE INS(. O� ` /
anystructure prlorto its batuance,alsorequlrestheapplicant forsuch permit to POWER DEVICES DATE
�a floe a signed statement that he is licensed pursuant to the pmvisium of the
3w Contractor.License Law(Chapter9(commencingwilhSect1on7000)ofDivi-
O�n SWIMMING POOL ELECTRIC
the
fo thealleend Profession. Any
)iolati hely exempt therefrom and VALUATION
G the bash for the aged�ects the
applicant
My t to acivi of penalty
on sea m n,any OUILETSSWITCHESFIXTURFS C L 6 ut s ..•0
five lamed apermit lars%S jells theapplicanttoadullpenaltyofnd morcthan L —lb (../��
$ five hundred dollars he pr. NEW RESIDENTIAL ELECTA
❑I,as owner of the property, SQFE STORIES TYPE CONSTRIX:HON'
p poly,or my empWe in with wage ee their door
compensation,will doth aworksessionstmdureh not Intended oroffered for
O
sale act apply
Business and Professions Code: Contractor's Umms Uw
5$ don nonsuch torn owner ofpmpertywho
nempor improvnted that such
OCC.GROUP RIS.UNIT'S
who doessuch worktIntededoroffe dis ow ate.It oweprovidedthatouch
improvements are not Intended earofred for cele.I[howe r-buil.buildingve TOTAL: I
Improvement V cold within oneycaro(compltion,theowner-builderwill have
tIqrden of proving that he did not build or improve for purpose ofsakd. QTY, PLUMBING PERMIT FEE H,pOD TONE APN
LJ[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE rt �.�m
contractors to construct the project(Sec.7011,Business and Professions Code: (�Cy
The Contractor. n License Law donot apply to an owner of property Who
builds or Improves thereon, and who contracts for such pi jells with a ALM-DRAIN&VENT-WATER CEA)
cgB(paCuria)licensed pursuant to the Coetradord License Law. FEE SUMMARY
L-1 I am exempt under Sec B&P C for this mason BACK FLOW PROTECT,DEVICE.
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIrf p
WORKMAN COMPENSATION DECLARATION 1�- Fp(•I•URFS PER TRAM' SCIi00L TAX V N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a _` A RECEIPT
N
mrtlfiatedWorkera'Comprnsation Insurance ora certlfkd mpythereof(See. GAS EA.SYSCEM•1 RJC.1 OI17LL'TS PARK FEE Y N
3800,lab C.)
Policy Y GAS E.A.SYSTQdAVER 1(EA) RECEI'T Y
Com any BUILDING DI VIS ION CIE ES
Certified copy is hereby(umhhed' GRPASE/INDUSTTRL WASTE INTERCEPTOR PLANCHECK FEE
rtlfied copy V(fled with the dty impeetlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEIVER-SANITARY-STORM EA 200FT Date RCCCI t#
Qhlsaection need CnotO becompleted I tithe b(Dronehundred dollars
(51 OOJOf1ea') WATER HEATERW/VFNT/ELECTR ENERGY FEE Y N
Icertlfy that person
mancerhework forwhichthisperm00l�ved, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/,TREATING
Wornt omperu5tlon laws of Callfomla. Data PAID
Applicant O Z NOTICE
Z O NOTICE TO APPLICANT;If,after making this fertlflate of Exemptlan,you N'E'W RESIDENTIAL I'LMB. SQ,f:[. Date . RCCeI t#
Fshould become subject to the Workdo Compersatbn provisions ofthe Labor TOTAL:
N Code,you rust forthwith comply with such provblons orthis permit shall be s
j domed revoked. BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEEL
I hereby affirm that them is a construction lending agency for the perform- ELECTRIC FEE
M Z an.of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE t
LL i— Iander>Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r
OmW Icertlfy thatl have madthisappllcallonand atatethattheabove information
1 isrred.I agree to comply with all cityand muntyordmana'hand state laws PERMITISSUANCE MCD FEES PAID:
N relatingtobuliding mnstructloe,and herebyauthorlaa representativesofthts
1— Z city to enter upon the above-mentioned property for Inspection purposes. At,=OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pert iso Date Reeeipt#
V agaI tlWbillti ' dgmen std a ed expenses which may In anywayaceree AIR HANDLING UMI'ITO 10,00CFM) SUBTOTAL•
again. In con nceegrenling of this permit AIR HANDWUNIT T(OVFR 10,000 CFM) CONSTRUCTION TAX
ignature of Applicary ontrador Data^ EXHAUST EIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAIZA R DOUS MATERIALS DI SCLOSURE
Willtheapplfa rat or future buildingocmpsnt.t.m or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCei t# _
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Heals hand Safety Cade Scalon2S532(a)1 HEATING UNIT 100,000 BTU) TOTAL• It
❑Yrs MN.
Will the eppliant or futurr bulldingompant sees equipment ordevicra VENTILATION FAN(SINGLE RESID) ISSUANC[•'DATC
Mich emit haeardous air contaminants as defined by the Bay Area Air
. lity Management Dlstrie? BDILER-COMP DHPOR 100,000 BIT])
Yes
Q4
(have read the ealth&%fet node,Se tors2rrenisunder Chapter. 1 of BOILER-COMP(OVER 1T0,000 BTU)
the understand
California 19ealth&Safety Code,Sectors 75505,have
a t and 25571. I ,l 'n/w�`!•"('�
Alia
understand that ifthethe building does note requirmnts tenant,that It troy NEW RESIDENTIAL MECH. SQFf
responsibility to ratifythe occupant ofthe requirements which must be mel � oil
prior to Issuance of a Certillate of Occupancy, nil
Owner or aulhorired agent Data / V---t
TOTAL: ISSUED BY:
OFFICE COPY