22227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
,B.ildl.g ProIdentification PERMIT NO.
Build ug Address: 22227
rcrs arae: [^� V - e: A
CITY OF CUPERTINO-BUILDING DIVISION
Con ao?sNaa!e Wc.No, APPLICATION /PERMIT
T� B=N—ELLCTRICALPLLIMBING-MECHAN)CAL CATEGORY CO a
Archlte,t/Englrear. [Ae Na l/
Q ELECTRIC PERMIT FEE, BUILDING PERMIT INFO
Address I'ERMITL$UANCE 1:1 ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION
thereby
affirm tbat l am l:cm l under provblons of Chapter 9(comuncro APPIIANCESRESIDENTIAL JOBDESCKIFTK)N
iogwitIke.h I.un]orce andly eft. ofthe Butlrusssud R.(odoruC.de,and y ^
Ikense b fs full force and effect. PANELS , 1 L' \ VP_ O\ 1
Daruc Glu Lk.#
Date Gontraeor —UP TO 200 AMPS
ARCHITECTS DECLARATION —201-IMO AMPS
a7 Iunderstardmy plant that)he used as public reourda OVERIODDAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
Licensed Prefmlorul 57GNSFT TMCAL A L E D
OWNER-BNLDER DECLARATION SPECIALCIRCUfT/MISC M P U T
/ �
t. lhersby dflrrnttutlun exempt fmumthe G.MraG.ri License l�wfor the
zzoo fa0oving reason.CeElon 70115,Buslnm and Profemloru Codr.Any city or
O Z TEMP.MEIIRt OR POLE NST.
�� � muntywhlch requlraapemdt tomvlruat,alter,Improve,dennWh,orrep 0 G. 2Q A I
S any.tmc mprurnlbb mu al.orequl theappBantfmauchpe ttL v 'i
4 file.slgned m
stateent that he b Licensed pursuant t.the pm risioru of the POWER DEVICES
Ow
Contract nesLkense Lw(Chapler9(mmmendngwMSeRun7(IW)ofDivl-
30 SWIMMING POOL ELECTRIC
slon3 ofthe Busd
Business and Prmuns Code)orthat he It exempt themfromarci VALUATION
y.' the hula for the alleged eaemptun. Any violation of Section 7m15 by any
applicant for a permR subjects the applicant to a cidl penalty of not more than OUTLETSSWITCHFSFIXTURES
No hundred ddWs(SS(lo). NEW REStDENT1AL EI,ECTR Fr,
1,uwrc
or of the property,or my employees with wages a.tMir role STORIES TYPE CONSIRUCTIDN'
mmpenatic�will do the work,and the structure bort mtemed or offered for
Osale(Scc 70K Busirussand Professions Code:The Contract.?.Lt..Law
$ dm rot apply to an owrer of property who bell"or Lmprovn Ihere.,and
F3^ who dm such work himself or through his own employee,provided that such OCC.GROUP RES.UNITS
Imprvverrcrds arc rot Intended orolfel/mak.IL however,thebulWing or TOTAL
impmvemerd bsold whhln omyearo/completion,the wvner-builder will love
"reienofprovingthn he did notbuildorimprovefmpurpo.eofuk.). QTY. . PLUMBING PERMIT FEE
LJ L u owner of the property,am excloed aively___g whh IfcemFLOOD TONE Al'N
PERMIT ISSUANCE
contractor.to emermd the propel(Sec.70K Businesaed profession,;Code:
The Comesc o?s Limrue Law dm eust apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
hu0ds or Improves thereon,and who contracts for such p(ojects with • FEE SUMMARY
INcior(s)Band pursuant to the Contractor'sLicense lane. BACK FLOW PROTECT.DEVICE
amexempt tool,Sur. B &P C /or this reason
y._
OIJTSIDE FEES
PurR SANITARY 7 Ner Date - DRAINS FI�OROOF, GOND. RECEIPT#
WORKMAN haw a J¢BATION DECLARATION
O1 hereby affirm I that Foss• rtak f-N
iOof consent to selertF)KLr�S PER TRAP SCHOOLTA% Y_ N_u
,or• RECEIPT If
¢rtNam of rkers'Compewll.nlnsuran¢ f�mpy t(�e GAS FIN.SYSTEM-1 INCA OLFILEI5 PARK FEE Y N
3800,V U 0 RECEIPT#
ldlry# GAS E.A.SYSTEMOVER#(FA)
Com Cry BUILDING Of VISION FEES
- - chimed mpyb herebj h,mbhed
DREASE/INDUSTRI,WASTE INTERCEPTOR PLANCHECK FEE
�Ccrtified mpyb(Iled with the cit n
CERTIFICATE OF O(EMPTION FROM WORKERS CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 300,'#. Date Rccci t#
Crhla section need nothe cmnploted B the SURA?b(more Fundi dollars
($100)orlu') WATER HEATER W/VENT/ELECTR ENERGY FEB Y N
I¢rtBy tLat lo the per(omun¢olthe work forwtdch this penult b bsued,
I dull not employ any person In any rnannm so as to become subject t.the WATER SYSTGI/TREATING
Workars'Compewtl.n U..f GBfomb. Dais PAID
-
0 = Applicant NEW RESIDENTULI'LMB. SQFT. Date Reaei t#
Z O NOTICE TO APPLICANT.If,after making this Cenfflate of Exemi or,you
Fshould become subject to the Worken'Comperuation provisions of the labor TOTAL:
CC N Code,you must forthwith comply with such provhuru.rthis permit shall be_ BUILDING FEE
W > deemed revoked.
ao cOIJsrris. oNLFNDWGAGENCY. SEISMIC FEE
I hereby workf that there i•construction lending 097,C for the perform-
Z FEE
7 Z andof er'. work for whlolu this pemdtb Wued 6ec.3097,CW.C.) TOTAL
LL O Ierde?.Name PLUMBING FEE
F L.nde" res. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W � Icertlty #havemply with
alfatb ndcountyordinmee, ndstat uawn -
1 rmrmY. toconuplywlth alltltyard county oedinanoe.and state lawn PFRh11T ISSUANCE FEES PAID:.
} 0. rtilating ilding mus" rd hereby author represcruti,e of this
Z tltltl!!!!llyyyyyy to a upon thefilLd.4harrolees
redtry fee inspection purposes. ALTFRORADDTOMECH. Date Rttel t#
_ e • to ovthe City of Cupertlri.against tie,,N^�dn which may lnanyw,y. nutFUNoulvc uNrr oro tD,DDD aI.D SUBTOTAL:
a 1 C urthe d bpertNt.
AP HANDLING INTr(OVE4 lQ(100CFM) CONSTRUCTION TAX
re p 4 1 ere, Date uSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H R DOUS MATER IA LS DI SU
Will the appBaudor nt etc or ha kh.rdoun HEATING UNIT(10 IDO,D00 SM Date RMC# t#
mrterblasde the Cupertiro Murdcipa 9.12,and the
Ilealthard Cade FffATING UNIT(OVER 10),"BTU) TOTAL:
F1 Ye No
WIIltheappRant.r tture building occupant use equipment mdevkxs VENTILATION FAN CSNGIE RESID) ISSUANCE DATE
whish creel haardcus air cvntamW nts as deflned by tM Bay Area Ab V.
'..
Quality
y Management District? BOILER-COMP OHP OR 100,000 RM
❑ R-�tlL'I have omad the hazardous materials requirements under Chapter 6.95 of BOILER-R7MP(OVER 100,ODD BM
the Calfomb Health&Safety Code,Sections 25506,25533 and 35534.t Jill Ae 1'#
understand that ifthelouilding dm not currently have stenant,that It is my NEW RESIDENTIAL MECI-L SQ.FT
resporuuWty to notify the occupant of the requirements which must be met
pror to Issuance of a Ceniflate of Occupaugla #y'
y. at /1 ypt10
u
Owner orauthodd agent Date ISSUED BY: a
TOTAL
OFFICE COPY