22787 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
Building Address:
'](o Om nva22787
IN—L L'o—sy QQ,Gi .r�� CITY OF CUPERTINO-BUILDING DIVISION APPLICATION B d I
Contractors Name: LIc.No: APPLICATION if PERMIT
S C,2-7110 BUTLDINGELECTRICAI.MBING-MECHAMCAL CATEGORY CO LJM
Architect/Eng11in� Lic.No: r 71
e
, . .^T 11 ' QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:2co Lcu,�ST- S1 , 'gF= W �NIO ( PERMITISSUANCE 1 ❑ ❑
LICENSED CONTRACfOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc. APPLIANCESRESIDENTIAL PHDESCRITION
IngwltI I fell
ell f reeanDlaftect ofthe Bumnessand ProfessloneCode,and rtry �.� �n►� p1N��. N _.N��+
lirensclsin(alit mond effect. PANES - 1 , ,\♦`�/K(�Jv
LlmnseC 1—Lk.N I VU MY✓
Dale Contractor 0Ik UP TO 200AMM
AR ,h it CI'SDECLARATION OVFR00 A.AM
q�q�vv
M, I understand my plata s1uI1 be used v pubUc recoNs OVER 1000 AMPS SQ.Ff.1Fl1.ODR AREA S/S/1Qa.Ff.
!z bo`j Licensed Professional 9tGNSELFCIRICAL 2`71
<�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC T 1
F, Iherebyaffi.that I am exempt from the Contractor's License law for the
Mrs following reason.(5m1on 70315,Business and Profenlorm Code:Any city or TEMP METER OR POLE INS(.
cwntywhichrequlmapemdttomrulruct,alter,impmve,demolbh,orrepalr
q11 .c a nystmMmpriartoltsissuance,atsorequimtheappliantfwsuchpemtto MWER DEVICES
E C file a signed statement that he U licensed pursuant to the provblom of the
�3 ContractorsLiceres,Law(Chapter 9(co urentl gwith Section 7")ofDist. SWIMMNGPOOLEECTRIC VA ON
f-�OS mon 3 of the Business and ProfesslomCode)or that he to exempt therefrom and D
5 the bash for the alleged exempllon. Any violatfon o(SWkm 70315 by anyOUILE•SSSW[7.C)TS FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than `�'� VN'•
five hundred dollars(S500). NEW RESIDENTIAL ELECTR SQ.FT. SfOWFS TYPE CON
ION
❑e as owner ll the property,or he employees with wages as thele sole q LED '
CJC mmponsadon,wllldess.rdothe r1c,and Predesthesbucture is he ut Contactor or offered for
in(Bee.70M,Buebiess and Professiore Cade:The Contractors License law
$g whodot apply torn owner ofp rough who employees,provided
that such and Uri r-arOrsnx
who eatsuch amrktirtanforthrough hlsownemp,hcxw,,eothe billing or YRVT7J E■�
improvements ithindneyearad fcomered or�le.the owevep Elder ill have TOTAL: N
improvement bsold within he did out Wil porim,thee for purpose
tryc�ar as..a,of of theing property,am exclusively
improve purpoath licensed
QTY. PLUMBING PERMIT FEE AFE°OD w
4101
Ltr L as owner tr the property,am exclusively contracting with s,Codd I —PERMITISSUANCE ew
contractors to ctaonawctthe project(Sec.appy Business and of pro oro Code:
The Coor J.p License law does oat apply to c, f owner of property who ALTER-DRAW&VENT-WATER(EA)
W Bds or Improvn thereon,and who mntnm for such plojeds with a
ryp{(adarts)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI(am exempt under Sec. B&P C for this re
awn DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner DatDELL RECEB NN
WORKMAN COMPENSATION DECLARATION FD('ILRFS PER TRAP SCHOOL TAX Y N
❑I hereby affirm That I have a certWlrete of consent to selLlnsure,or a RFCEIIrf N
certificate ofWorkeri Compensation Insure en ora cenifin]copy thermf(Sce. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ RECEB'T N
Policy N GAS F.A.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Com ny
OCertlfed copy l9 hereby furnlahed. rAll
�C,mified copy is filed with the city Wpection division. GREASE/WDUSIRL WASTE IN'fEACE'TOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP ��oS
COMPENSATION INSURANCE $EW FR-SANRARY-STORM EA 200FT' Date Recef t#
(This section need not be Completed 9 the permit V for one hundred dollars
($1 BIB or less.) WATER HEATER W/VENT/ELECTR ERGY FEE Y_ N—
I certify that In the performance of the week for which this permit Is Issued,
I shall not employ any person in any manner no w tq arbjad to the WATI]i SYS7PM/TREATING
Warkcri C sailors yd Cae�rnlan�Date L . P ID
O Z Applicant t�KF1Yi�/ p/J�/J NLIYREADFMIALPLMB. SQFT. Date RCceI t#
Z O NOTICE TO APPLICANT:If,titer making this Certificate of Exempeon,you
should becomesubject to the Workers'Comperuat1w Emulate of the Labor TOTAL:
I— N Code,you resat forthwith comply with such provisions orthis pereent shall be INC ' E
Uj j deemed revoked. SEISMICFEE
W CONSTRUCTION LENDING AGENCY
d Ihereby afflrmthat there V a construction lending agency for the perform LECTRIC FEE
� Z once ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: �_
O O I<nderb Name P UMBING FEE
LL F- Lender§Address QTY. MECHANICAL PERMIT FEE M •CHANICAL FEE
U Icenifythatlhavi,.dthtsapph.tisnandmalelhAtheabovelnforreatlon F ES PAID:
O W rrect.l agree to comply with all city and county ordinances and mate laws PERMIT ISSUANCE
). V) relating to building corotructioq and herebyauthorbe representatives ofthls
Z city to enter upon the above-mentioned property fee bupection purposes. ALTERORADDTOMECH.
_ Date Receipt#
(We)agree to save,
ent,on(yan.ed.repharratess es whihthe City of Cupertino AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
V agalmtliabilities,judgments,mmaand expenxs which may in anywayaccme
aga Ity lm tyuenm ar the gr ting of cola permR. ONSTRUCTION TAX
NR HANDLING UNIT(OVER 10,000 CIM)
Sigruture of pUcaut/Co racmr D e EXHAUST HOOD(W/DUCT) ONSTRUCTION TAX PAID:
HAZAR OUSM ERIALSDISCLOSU E _
Will the applicant or future build gocmpantstore or handle hazardous HEATING UNIT 100,000 UTIs DatC RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
I Ieallh and SafetyCade Scctlon 75532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Y. MN.
Wllltheapplicant orfuWmbuildingacaapantuseequlpmentordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contanereants as defined by the Bay Area Air
Iity Management District? BOILER-COMP(3HP OR 100,000 BTU) P A RA
Yes ❑F�1 No A!M
shave mad the bazallous materiab requirements under Chapter 6.95 of BOILER-COMP(DVI]t 100,000 BTU) (�
1 the Califomla Health&Safely Code,Seat Ions 25505,25533 and 75534.1 �C�
u relents ad that if the bu llding does not currently have a tenant,that it is my NEW RESIDENTIAL MSCI I SQ.FT
responsibility to notify the ocm pant of the requirements which must he met
prior to issuance of a Certificate of Occupancy. citv at
*50
Owner or authobted agent Data ISSUIM BY:N/, - C-L
TOTAL:
OFFICE COPY