22727 APPLICANT TO FILUN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject ldentlfleatlon PERMIT NO.
BaiMiOngAddresg: - _ - ;
22727,
one.a CITY OF CUPERTINO-BUILDING DIVISION —c7c ant Lk.Na.' APPLICATION / PERMIT .
a BUILDINGELECTRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL#
A hit a Lk.No: •
'Alar 1` tI•ELECTRIC PERMIT t ` ':GS,:IBUILDINGF,EILMITiNFp .
AddreLICE
NSEDCONTRACTOR'S DECN
PERMITISSUANCE [:1 - • .E:1� '
L][
hereby affirm that lamlicensedunder ansofChapte (cornmene. APPLIANCES-RESIDENTIAL JQB DESCRB']TON+
ingwith5colon7000)ofDlvlelan3oftheBusinemandProleian.Code,and my
' PANELS le In to rforce andeffec71 4
Lt. Cis k.# •n/
'
• 0 r y -
Date Contractor (�1-., UP 200 AMES
ARCHITEC'SD ATIO 201-1000 AMPS ^
q�u pO Iundentand my Alarm shall be used n public records.. OVER 1000 AMPS, t n SQ FT R - S/SQ.FI.
SIGNSELECTRICAL
up- Licensed Premmilmal
<6P� OWNER-BUILDER DECLARATION
I'n Z Fa SPECIAL CIRCUIT/MISC _ f
a, � •Iherebyafflrmthm
atlaexemptfromtheContractureLicenseLawforthe 1 J
Z following reason.(Section 7¢315,Business and Professions Code:Any city or
O aTEMP METER ORPOLE[NST.county which requiresa permittomoatruct,alter,meP rove,dertnllah,orre ir
to
O/
q' any atruduretatementshatheeis lice ser pursuant to the ro inions of to POWER DEVICES'
file a signed statement that he is licensed pursuant to the provisions of the
Ow Contractor's License Law(Chapter 9(mmmenclng with Sadon 7000)of Dial.O� VALUATION 0 don3 ofthe Business and Professions Code)orthat he is eaempttherefromantl SWfM'bBNC POOL ELECTRIC ,the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETSSWITCHESFIXTURES x
applicant for.permit mubje. theapphcant toa civil penaltyof not more than
live hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. TYPECONSTRUCTION
STORKS
..�, ❑I,as owner of the property,or my employees with wages as their sole
7a compensation,will do the work and the structure isnot intended or offered for -
O sale(Sec.700A Business and Profession.Code:The Contractor.License Law
�2 does not apply to an owner of property who builds or improves thereon,and OCC.GROIIP RES.UNITS
^ who doessuch work himselforthrough his own employees,provided that such
improvements are not intendederoffered formals.If,however,thebuildingor - TOTAL:
improvementissoidwlthinoneyearofcomplelk theowner-budderwill have to-„ �t`• -
tl�urdenofprovingthathedidambuildorimprove for purpose of sale.). (�jy;�•�j;+'�+;,:�`;PLIJMBINCi tPERMTTt,St;;i;; ;; ,pph. 'yy',1 F1ppD ZONE APN
u 4 as owner of the property,am exclusively con—
t
on— lne mth Ikenssd PERMIT ISSUANCE py
contractors to construct the project(Sec 7D44,Business and Professions Code:
The Contractor's License Law does mat apply to an owner ofProperty who
buALTER-DRAIN&VENTWATER(EAJ
Wild.or improve-thereon,'and who contracts - -
for much plojents with a c `"F :
cgedjpactor(s)Iirdaed pursuant to the Contractor'sLkeme Law, BACK FLOW PROTECT DEVICE "EE,$
T)MMAII,Yi
6I am excerpt under Sec R&P C for this reason
Owner Date - DRAINS FLOOR ROOP,ARRA,COND. SANITARY Y— N_ -
WORKMANCOMPENSATIONDECLARATION RECEIPT# -
❑I hereby affirm that I have a mrtificate of consent to calf-insure,or a FIXTURES PER TRAP SCHOOL TAX Y_ N
certif cats of Workers'Compensation Insurance or a certlfkd copy thereof(Sec. RECEPT#
3800,Lab C.) - GAS EA:SYSTEM-1INC.4OUTLETS PARK FEE Y— N—
Policy#' + - RECEB'T#
.. Cmany CAS EA.SYSTEM-OVER4 MA)
BUILDING DIVISION FEES
otrCertuied copy Is filed with the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
_ �CeaBled copy b(Ikd with the city inspection divi4lon. - ,.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
"COMPENSATION INSURANCE SEWER-SANCCARY-51URM FA 7IgFf Date Remi t#
(Thbaection need not be completed lithe permB Imfor,one hundred dollars
($I I comlythat in the performance of thework forwhich this permit Is Issued,less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y - N-
I shall not employ any person in any manner w as to become subject to the / WATER SYSTEM/TREATING Vim•
' Workera'Compensalion Laws o(CPAIDalifomia.Date S ,.
Q Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. 'Date Recei [#
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
shmldbem subjeatothe Worken'Compomation provlsiaruofthe Labor - TOTAL:
- Code,you moat forthwith comply with much provisions orthis permit shall be I DN •E -
deemed revoked.
-W C CONS'iRUCT1ON.LENDING AGENCY - SEISMIC FEE
a I hereby affirm that there is a construction lending agency forthe perform- - O ELECTRIC FEE
D Z arm of the work for which thin permit is Issued(Sec.3097,Civ.C.) TOTAL -
U O Lenders Name PLUMBING FEE "
IL F Lender.Address QTY MBCHAJICALI`PERIv1IT rt `k•'•FESC:''•' MECHANICAL FEE
OW Iredifythat I have read thlsappllrationand statethattheabove lnfomatio
CL - Imminent.I agreeto complywlth all city and county ordinances and slate law. PERMITISSUANCE FEES PA
N m
J�n}:
>- relating to building coetructton,and herebyauthorizerepresentativemofthls
E ��'/6•'7/ b�obo
(_ Z city to enter upon the above-mentioned property for inspection purposes, ALTERORADDTOMECH. ' '(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReCel P[#
against liabilities,Judgments,mks and expenses which may In anywayaccme AIRHANDLINGUMT(T010,000CFM) SUBTOTAL''
against said City in consequence of the granting of this permit. -
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Signature of Applicant/Cortncior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION.TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfuture building oavpant store or handle hazardous HEATING UNIT(TO l W,000 BTU) Date RL'Cel t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Cade�+.NN. 25532(a)P HEATING UNIT(OVER 10G DDO BTU TOTAL'
❑Yes u No
Will the applicant or future building occupant time equipment or d calces VEMILATIONFAN(SINCLERESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air A
Quality Management District? BOILER-COMP OFT OR 100,0W BTU PM'®
4 Yes F�No f_M. .
havereii the &r ileus materials regal 25505, under Cha ptei.1 of BOILER-COMP(OVER 100;OW BTU)
the
understand
to Health&SafetyCode,Sectionsally haves
s tenant,and 25534.I' -
undentanlitytofthe tifythldingdcemnotmrrentlyhavtmwhichneekbemat NEW RESIDENTIAL MECH. SQ.Ff SEP �. 1 �1
responsibility to notify the nt o(the ircments which must be met
rio Issua a [Oce[ Occupan �I Cap I Q
recur.. rizedaRmt Date T
TOTAL: ISSUED BY:
OFFICE COPY