22172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ero'en Identification PERMIT NO.
Build in Address: /�
e9Pl NO VIP re— 4 22172
wnera ante: one:
p / A
G// >e —rOoa CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: �a� � �T a� Lie.N. APPLICATION / PERMIT S L 6_CA i
OO L G 15AA �/1• JZZZ� BUILDINGELECMCAL-MU BIND-MECHAMCAL CA7FfARY CONTROL N
Archite /Engineer. Lic.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 12-M ❑ ® ❑ ❑
LICENSED CONTRACTOR'S DECIA ATION
I hereby 7Dthatlamlcensedhe Busirovlslon fChioner9(commenc MPIdANCESRESlDENTIAL JOB DESCRIPTION
Ingwith Sectlon7000)of Dlvblon3oRFe Rusin rofessione Code,and my
license is In fulLforcomd effM. PANELS
Wmoea Clam Y—^I LJ Lich l
Date Contractor UP
PTO 200A 5
ARCHITECTS DECLARATION OVERI000AMP5 LSQ.�.p AREA $/SQFT
�J I understand my plain shall be used as public records. '
GO
U(0 Licensed Professional SICNS ELECTRICAL
¢nt OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC P U T
lhembyaffirenthatlam exnmptfromthe Contractor's License Law for the 3 E R
followingreason.(SecUon 7m15,Businessand Professions Code:Any city or TEMP.METER OR POLE INST.
P4ryy.a countywhichmrylnsapermottomretruM.Iterimpreve,demolbh,ormpalr /-2 '
.a anystructure prlorto Its Issuance,also requlreothe applicant fen such permit to POWER DEVICES
Die a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(mnurcncing with Section 7000)of Diel- SWIMMING IDOL ELECTRIC VALUATION
O aIoR1 ofthe Businesaand Professlom Code)orthat be is exempttherefromand
< the Fools for the alleged exemption. Any violation of Sectio7WIS by any OUTLETSSWITCHESQFIXTURES f 1•05
O
applicant for a permit subjects the applicant to a civil penalty of nM rmre than
�4 five hundred delta.(8500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES 'IYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
C?C compematton,will do the work,and the structure b not Intended or offend for
5 ❑ vie(Sec.7,W4,Business and Professions Code:The Contractor's Limeon Law
docs not apply to an owner of property who builds or improves therron,and OCC.GROUP RES.UNITS
who doeasuch work himself orthrwgh his own employees,provided that such
Improvements are not Intended oroRered(w sale.If,however,thebuilding or TOTAL: l
Improvement b sold wilhln one year o(completloM the owner-bullderwill have
tlrjvrden of proving that he did not bund or Improve for purpose of ask.). QTY. PLUMBING PERMIT FEE FLODD ZONE MN
u L as owner of the property,am exclusively contracting with limned PERMIT ISSUANCE
cont.cton to coretmct the projM(Sec.70d4,Business and Predessloru Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER ff.NN
bulks or Improves thereon,and who contracts for such ptojec s with a FEE SUMMARY
cglLtnRoRs)licensed pursuant to the Contractors Limnos Law.
LII am exempt under Sec B k P C for this reason BACK FLAW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_r
• Owner Datc RF-CERN
WORKMAN COM S ION DECLARATION FIX.nIRFS,PER TRAP SCI{DOL T'A% Y N
❑1 hereby alflrm that I have Rate of consent to vel-Insure,ora RECEIPT Y
certi(IoteofWorkeis'Com o murance ora certified copythereof(Sec. GAS EA.SYSEEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.) / R/ RECEIPT N
Policy N / CAS F.A.SYSTEMAVER 4(EAI
ray BUILDING DIVISION FEES
ertiB Icopy ta he fumbhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ta fi e i with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-S ORM FA p0E-f. Date Receipt#
(Thlssectlon need no be completed lithe permit is for one hundred dollars
(5100)or less.) - WATER FIEATER W/VENT/17.ECTR ENERGY FEE Y_ N_
I rertifythat in the performance of the work for which this permit is issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
O Z Applicant NEW RES D[NT AL PLMB. �.T. Dale Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the Worken'Compensatlon provisions of the Labor TOTAL:
CCN Code,youmust forthwith comply withsuch provbiavorthb perretshallbe, BUILDING FE
W > deemed revoked.25 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affirm that there B a construction lending agency for the perforin ELECTRIC FEE s
7 Z ante of the work(or whi<h this permRd Lwued(Sec.3041,Civ.C.) TOTAL:
00 lsndersName PLUMBING FEE
LL h Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irertlfyt'atl love read thbappliotionands ethat theabova ln(ormatlon
W 6mrmet.lagree to comply with al ctya d ty ordinance and state laws PERMITISSUANCE FEES PAID:
- N relating tobullding<onsWRlon,and he by horuerepresentativesofthh
Z
city to enter upon the above-mention ro for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,in coed an kn harmless,the city of Cupertino Date Receipt#
V againstllabi@in,pdg n, a e ses which may In anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaimt said City 'nB of this permit.
( III AIR HANDWNG UNIT(OVER I g000CFM) CONSTRUCTION TAX
igmmm App nt/Contract Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Fbk ARDO ATF.RIALS DISCLOSURE
Will the a pplicant or future building occu pant store or handle haeardouc HEATING UNIT(TO l00,W0 BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Stolon 7553I(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 1
❑ Yes No ss�'�
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ��C)//ANCE DATE
which emit hazardous air conlambunts as defined by the Bay Area Air
Quality Management District? BOILER-CAMP DFIP DR 100,000 BTU) MAY 6 ����
Yca No
have read thehua oua materials requ fit under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the Callfomia Health&Safety CCde,Seetio 50 75533and2SSM.1
urderatandthatifthebuildingdoes not oti aveatenant,thatittsmy NEW RESIDENTIAL MECH. EQ.FT. Irldaa sr/f/6,
respoiuibilitytonotl the panto( a meets which most be met
prior to Issuance of ca of my
Owner or ori
Data TOTAL: ISSUEIV D BY:� T
OFFICE COPY