22072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuUdina Proles Identification
(� FJ' c ,PER.WT NO.
Building 10-78q' ��F�YC 17�F J� �E; I
-�nenmPame: hone:
{� At'PW(:A I ION SUHMI IIAL DA h
LSeLT-6439-�c-f+ CITY OF CUPERTINO-BUILDINGDIVISION
Coy�a��I/Q�•N•pv�y(���/ `["�� Lie.NNo APPLICATION I PERMIT
I—J.-•"-'S° `�`^�e ` r �� 3 eU1LD1NGELECTRICAI.PLUMBINGMLCHAMCAL' CATEGORY CONTROL N
Arebltect/Enginnr. Lk.No: L 1
,',!ELECTRIC PERMTT,(';' `rEE," '. BUILDING PERMIT INFO
Addcar: ILOU bL l PLIIMH--
I, (PERMIT ISSUANCE I� (xI `L 'S f� .
LICF.NSF.DCONTRACIOR'S DECLARATION Lz.J L17 L�J _J
I her offhartliat l am licensed under provisions of Chapar9(commene-I APPLIANCESRESIDENTIAL
ingwlth Section 7000)of Divislon3 afthe Businenand Profnslona Code,and en 1 JON DESCRIPTION ^
license lain full f d affect. �/ .•� y PANELS I �2 f'1•i-4.L. 'j.Q-'L��
License Date .Lj«�enai 1c.Contractor 5
ARCHall SDECLARATIO OVER IIlAMI'S ,
p� 1 understand my plans shall be used n public recortls. � OVER 1000 AMPS I SQ.FI.FLOOR AREA 4/SQ.FI.
p��uu ° { AL. E.D
tti� Licensed Pro(esslotul I SIGNS ELECTRICAL IC' (�� I��i
G
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC ■ jim P U T S
OWNER-BUILDER v following reason.(SeR1on 7031 S,Buslneu and Pro(emlons Code.An d orF71" nessand Code. ap.r TEMP.METFR ORIOLE INST.
any structure Prior to its Issuance,also requires the applicant for such permit to POWER DEVICES ,
� I
a U file a signed statement that he ls licensed pursuant to the proviion of lh•
°w Contractors License Low(Chapter9(mmnrnciogwithSection7000)ofDlvl-
�ECj slon3o(the8uelnes.andProfesslmn Code)orthat he Ls exemptthere(roman^ SWIMMING POOL ELECTRIC � VALUATION "
yyr0� •--tt the bash for the alleged exemption. Any violation of Section 70315 by a y O
p« applicant fora permibubjectsthe appecanttoacivil penalty of not more than
� OUTLE'ISSWITCHFSFIXIlItFS I �I �I �' OOO CI�RKJ '
a five hundred dollars($500). NEW RESIDENTIAL ELECTR
r-1 SQ.FT.I I STORIES M'E CONSIRUC'HON
�n I,as owner of the property,or my employees with wages as their sol•
compensation,wiildo the work and thestructure Is not Intended or offered for
D sale CEOs 7044,Business and Pra(essious Code The Conhact.e.License Lac
whodot .uels loan owner orprough his onemorlmprovnted that such •�� I OCC.GROUP RES.KNITS
t does otapply work an owner orthtoughhleo builds rimpprovided themes, d - - -
improvements am rot intended orofferel forsak.IL however,thebuildleg or TOTAL:
r powement bsold within oneyearofcompbtlon,the owner-budderwlll:.
1 rden of proving that hadid not build or improve for purpose ofxak.). IQTY. ' ' ", PLUMBING,PERMIT ",I' 'FEE FLOOD TONE APN
L1,as owner of the property,am exclusively contracting with ties' PERMIT ISSUANCE
f^ •!`YN
conteecton to construct the project(Sec.7044,Business and Professions Code: I I L ` "III
The Contractor'•License Law don not apply to an owner of property wh, ALTER-DRAIN k VENT-WATER(G)
builds or improves thereon,and who contracts for such pmjecta with a I
off.ctor(.)Uremad pursuant to the Contractors License Law. i" FEE SUMMARY' i•
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE - I I • ' n1IT¢1111:"I 1
Owner Dail - DRAINS FLOOR ROOF,AREA,COND. I (SANITARY Y_ N
RECEI p
WORKMAN COMPENSATION DECLARATION ITKTURSS PER TRAP L (SCHOOL TAX Y N_
❑I hereby afOrm that I have a rortiUcete of coroent to self-Insure,or a .I -O REC I.PT N
unifinte ofWorkera Comp...un insurance.'.certified copythereof(Sec.l GAS EA.5YS1'Qd-1 WC.40UTLEIS I (PARR FEE Y N
3800,Gb C)
P.hey if RECEIPT N
Co at any GAS EA.SYSTEM-0VERI(EA) I I - B UILDING OI VISION FE ES
I�can+aee-ropy bt hereby hecit. GREASE/INDUSIRL WASTE INTERCEPTOR I PLANCHECK FEE
Cenif ed copy ls hereby for he dry lrupectlon divhlon.
CERTIFICATE OFCXEMPTION FROM WORKERS' -(GREASE TRAP , I PAID
COMPENSATION INSURANCE
(Thissectton need ncv be completed if the permit is for one hundred dollars SEWER-SANITARY-STORM PA.100F1'. Il Date Receipt#
($100)otifyth WATER HEATER W/VENT'/ELECTR I ENERGY FEE Y N
(hoot that in the person in theworkwastobco eernitis tothe —
1•lull not employ any peas In any manner was u to become subject to the I WATER SYSTEM/TREATING
Workers'
an Compensation laws or California. Dal- PAID 'O Z Applicant
Z p NOTICE TO APPLICANT:If,after rtuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. I _ I Date , Receipt#
Fshould become subject to the Workers'Compareation provisions of the Labor 1� TOTAL:- IJ /1
W Code,you mu at fen hwith comply with such provision•or thin permit shall bet I BUILDING FEE
P-lLe�fl
W j deemed revoked.
CL CONSTRUCTION LENDING ACLTVCY I SEISMIC FEE C`t 0
lherebyafOrm that ichthisaermit 0 otied(Secgag7,Civ. .) perform TOTAL: ELECTRIC FEE Iq,po
Z ance of the Therebwork for which permit LSwed(Sec. agency for I ��
00 lender'sNary ;PLUMBINGFEE ZUs
LL h Lander's Addresa - �QTr. MECHANICAU;PBRMIT. I" FEEj`,tMECHANICAL FEE
U 1 certifythat l haveread thin application and statethatthe above In formation
O 1 Is correct.I agree to comply with all city and county ordinances and state laws) PERMITI55UANCE; I (FEES PAID:
} W relating to hot[ding construction,and hereby authorize representatives of th6 I7
H Z city to enter upon the abon mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei t#
V _ (We)agree to save,Indemnify an d keep harmless the City of Cu part Ina P
�Ap
jodments ronteand e apenses whkh ma in anwa accrue AIR HANDLING UNIT(CO 10,000 CIW) I SUBTOTAL:nce of the granting of this permit/} .9 AIR HA NDLING UNIT(OVER 1 g000 CIM) CONSTRUCTION TAX
Sll gw sractor(J/ /C 4 to //- E%HAUSIHOOD(w/Dllc]) I CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL SUR
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) I Date
material as dearest by the Cupertino Municipal Code,Chapter 9.1Z and the Recef pt#
Ilealth and Safety Code Section 25537(a)7 I HEATING UNIT 100,0(0 BTLE, I I TOTAL: LA
❑ Y. MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAN DATE
which emit hazardous all contaminants.,defined by the Bay Area Air p{
Quality Management District? BOILER-COMP OHPOR 100,000 8TU)
4 Yes Tinto
havcmia ealth&Safety mater,Sections 25505,25533 aChapter.98 of BOILER-COMP(OVFR 1011,000 BTU)
the= d to Heahhk Sldin Code,Senlmuntly have a tend,that It
understand that notify the occupant not the requirements have which thatb lsmy NEW RESIDENTIAL MECH. �.FLI
responsibility(sate notifytheiate of o!therequlrcmentawhich must be mM
prior to Issuance of Gniflota of Occupancy. . I' �•� {µCU`�.rd
Owner or authonred agent Data
TOTAL: ( (ISSUED BY�
OFFICE COPY