22665 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification I PERMIT NO.
�ullding Addreu: cent is D 22665
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�Co�T "'140 '79C-Of CITY OF CUPERTINO-BUILDING DIVISION
Contrado arm: I Lic.N.: APPLICATION I PERMIT
BUfLDINC-ELECTRICAI.PLUMBIN'r— LHAMCAL CATEGORY CONfROLY
Architect/Englnesr. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: 1
LICENSED
EDCONTR DECLARATION
PERMITISSUANCE
Ib fl7eathatlamlkmunderrro hamrnAPPIlANCESRESID
ENTIAl
IthSlon70W)ofDivi3o(theBusJmandPmfWm&Code,andyJOB DESCRIPTION-,^�
t...1.In force and effect. PANELSLlcarseCbma
Qt
ortr I 1 o�r/Vt�/(JJ1Jsi
Dale Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 201-10DOAMPS
q�q�vu O use
I understand my plan shall he d as pubaco
c records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNSELFGTRICAL
OWNER-BUILDER DECLARATION SPECLALCItCUIT/M1SC
i,, IhambyafRrm that l am exempt froarthe Contractors License Law for the
p q following rcaeon,(&dlon 7811 S,Businessand Professions Code:Any dty or
PZt'uy mentywhlch requires permit to construct,alter,Improve,demolish,orrepair TEMP.METCR ORPOLE INST.
q� la7 anyamacture prior to its aseance,alaorequirestheappllont forsuch permitto (OWER DEVICES
PS M U file a signed statement that he Be licensed pursuant to the provbiora of tM1e
3u, Contractors License Law(Chapter 9(co0mrntlng with Seaton 7000)of Divi.
�Og slon3 oftheBusiness and Prof.hmsCade)mthat hefsexempt there(romand SWIMMING POOL ET.ECTRIC 11 VALUATION
< the basis for the alleged exemption. Any violation of Section 70115 by any UTLETSSWITCHESFTXTURES 1 000, od
appli.at fora parent subjeeathe applicant to a dvll penalty cf nam .than 7
aive his"dred doll..%. NEW RESIDENTIAL ELECTR
ear of the property, —5Q.FT. STORIES TYPE CONSTRUCTION
p party,or my employee with wages as their sole
7a c peas)tion,wllldothe work and thestrudure is not Intended or offered for
O e(Sec.7074,Bushassand Professlmm Code:The Cnnlrad.e.Llconse Law
[� nes n,
not apply to an owner of property who builds or improves thereoand
w� hodoessuchw rkhbTmlforthroughhisownemployees,provldedthalwch OCC.GROUP RES UNITS
improvements are not Intended oroffered formle.It,however,lhebullding or TOTAL; t
Improvement bsoldwithinoneyearofcompldiorythe owner-builderwlll have
t"rden of proving that he did no.bulldorlmpmve(orpurposeofule.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
U I,as owner of the property,am exclusively contracting with licensed
PERMITISSUANCE .rvl
contractors to construct the project(Sec.7044,Business and Professions Code: LY
The Contractor's License Law does cast apply to an owner of property who ALTER-DRAIN VENT-WATER(EN
Wilds or Improves thereon, and who cont.ds for such ptojects with a FEE SUMMARY
c,,IlIltjjador(s)licensed pursuant to the Comment's License law.. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Set as
B k P C for this mon
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data �.sat RECFR'f p
WORKMAN COMPENSATION DECLARATION FD(TURE'L PER TRAP W SCHOOL TAX Y_ N
❑I hereby fit.orkem that I have• l r rate of consent to spy thea ora RECEIPT Y
3800,La C.Worke7e'Compensa.lonlnsuranmmaceelfled copy thereo((Sec. CAST EA.SVSEEM.1 INC4 OUTLETS PARK FEE Y N
3300,Lab C.) RECEIPT Y
Polity Y GAS EA.SYSTQ.1-(S_�ER�oup
Com any � BUILDING DIVISION FEES
�Cadmedcopybhedwithtecityreby forro,locf. GRFASE/LNDUSTRLWASTE i' PLANCHECK FEE
Cedl0ed copy b filed with the tlty ImpedlOn dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID _ c ry�
COMPENSATION INSURANCE SEWER-SANITARY STORM FA.200FT. Date Recel t# J�•`^'
Rhe,seelon need out be campided lithe permit b foram hundred dolls.
a10°)mfesJ WATER HEATER W/VENT/E.ECTR ENERGY FEB Y N
Icedlfy that bthe performance of the work for wNcM1 this permit is based,
1 shall not employ any person in any manner so a to beroma subject w the WATER SYSTEM/TREATING Workers'Compensation Lawsof CailfomIa.Data PAID
0 Applicant NEW RESIDENTIAL FILMS, SO}T. Date Recei t#
Z Q NOTICETOMPLICANT:eWorrma Compking lssatim pro is Eve of the
should become subject to the Work<n'Compensa/lon provisions;o(.he Labor TOTAL:
P
N Code,you resat forthwith comply with each provblom orthb permit shall be BUILDING FG
W >. deemed revoked.
CL
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby efRrm that there b ar
I.. mlmction lending agency for the perform- ELECTRIC FEE
7 Z ance ofthe workfor which this permit la bsued(Sec.3097,Civ.C.) TOTAL:
O O Lenders Name - PLUMBING FEE
LL h Lnnder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mdifythat l have read thbapplicatbnard st.mthat theabove Information
4 lacorrce.I agree to comply with all city and countyordhanees and Mate laws PERMIT ISSUANCE FEES PAID:
>- N relating to building comoudlm,and hereby authorize representatives oftM1b
H mm
city to enter upon the above- entlod proprty efor Inspection purposes. ALTERORADDTOMECH.
Z V
( agree to save,indemnify an d keep harmless the City of Cupertino Date ROcei t#
against
sabllltln,ludgmente,roeund npensn which may In anyway ace7ue AIR HANDLING UMT(TO 10,OOO CFM) SUBTOTAL:
against ui ty In roes ecce of the granting of this permit.
G, ,fl AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION TAX
Igmtu. ppll nt Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATARDOUS MATERIALS DISCLOSURE
Willtheapplinest or(umrc building occupant store or handle hazardous HEATING UNIT HD IDQODO BTU) Date Recel t#
material as defined by the Cupertino MuraNI Code,Chapter 9.1$.and the
I lealth and Safely Cade Section 25532O)7 HEATING UNIT(OVER 100,000 BTI)) TOTAL:
F1 Yes b Na
Will the applicant or hours building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whicheMhaa4awls as defined by the lay Arca Alr
.
Quality Management Dlslrid? BOILER-COMP DIIPDR 100,IXI BTU)
IQ.Y. 4 No
haveread the halth A, oety CodriSectioulrem05,25533 and 255M. 95 of BOILER-COMP(OVFR 100,00)BTU)
'he
eraCaltfombatIftebSafetyCode,Sedlonsntly have
a tend,that 1undW�
rmporuandthz.notify
the ing doesoccupant
ofnot herreuirecrves which,thatRbmy NEW RFSIDFNI7AL MECFi. SQ.IT
rmpr to Iss a ce col Rythe occupantofthe rcqulremenb which must be corm y„
prior to issuance of a Ceel0cete of Ottupanry. @LCbY.
Owner or authorlmd agent Date
TOTAL: ISSUED BY�A4/ 1 r I
OFFICE COPY
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