22933 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: JD 2, 2 2 9 3 3
weer i - one: .
bG CITY OF CUPERTINO-BUILDING DIVISION
ontratlnr ame: - 'LIc.No: . APPLICATION I PERMIT
Architect/Engineer:
Lie.No: BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CO L*
R'p',.:.y +tt$GC2'RIC PEii11.11Tt'- t i,,tFBE, "ts'''; $UIL:DING PERMI,'�,WFO
Address: _ PERMITISSUANCE ❑ ❑ .
LICENSEDCONTRACTOR'S DECLARATION - FN
Ihamby affirenthat lamlicensed under provlslonsof Chapter9(comment, APPLIANCES-RESIDENTIAL - JOB DESCRIPTIONingwith Section70WBof Divisbm3 ofthe Businessand ProfestlonsCode,and my -
license Is In full jaand effect. PANELS
License Cla Lic.# - l�
Date Contractor - UP TO 200 AMPS r
- 'AROUTEC'S DECLARATION 2014000 AMPS -
aZ I understand_my plane shag be used as public record& OVER1000AMPS. SQ.IT.FLOORAREA $/SQ.FT.
Q�uDDqG
Fi X U Licensed teselovl SIGNS ELECTRICAL �
eau - OWNER-BUILD ER DECLARATION SPECIALCIRCUIT/MLSC - !'�• O
Z F a FiI hem
rebyaf0rthat l am exempt fmmra
the Contctoes Lima.Law for the -
po Yd following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z t-. TEVR'.METER OR['OLE]NST.
F� a, cmntyanystm hkh regrtois pe ttoame,mrutmctimsth,lmpbuntf rslch,er ttr
a any.signere tgem ire Issuance,alcensed pursuant
to the
rovisi rat of t e ppyYEg DEVICES
(Ile a signed statement that he Is Ilcenxd pursuant to the provbloria of the '
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC -
f+ sfon3ofthe Business and Professions Code)orthat he is exempt therefromand VALUATION�sy.
E5 •77 the Wals for the alleged exemption. Any violation of Section 7031.5 by an W
$B 6£ UTLETSSWITCHFSFIXTURES
y� five hundred
apermRsubjeitstheapplkanttoativll penalty of room
pj o liF11,as owner of he pr, NEW RESIDENTIAL ELECTR SQ. STORIES TYPE CONSTRUCTION
QQQQQQ �I,as owner of[hewilt s worky,or my employes with et ended thele sole
G compensation,Business
Professions
Code:Th Contractor or imme Law
q d for
dile(Sec.apply
to alnow end f property Code:The Contractors hereon Law
3$ doesnotapply tork ownerofpropertywhobuildsorImprovsthereoryand O
impwho d e ntsmrkhlmse dedoroughhieow le.1,oases,pr the uildinthat such
Improvements wld Ntendneyear fconiprsak.Iheh nv buflderwilf ve O I�A P
ttLj1,as ower ing of the prodid perty,am
build or Impreve for
contracting
with
cofune Q'Ijt 4;,;�t PLUINBING.PER16fITtt '"::FEB`ti FLOOD ZONE / IN
Ltr I,as owner of the property,em,exclusively70K Buss contracting with licensed PERMIT ISSUANCE DATE
TheconCotore to co stmdLicense
e L project(Sec,apply
to need and of property
Code:
The Contractors es tkse Lw does h apply to an owner Dir property who ALTER-DRAINAL VENT-WATER(EA).
Wilda or Improves thereory and who mnirecb for such ptojacts with a
cgDtfactoKil hoerund to the Contractor's License Law. Cj�; y ,i 1:[:Pt$IJ]VIMAR „•
LJI amexempr'und)rt'untler Sec. B k P C for[hh,reason - BACKFLOW PROTECT.DEVICE
Owner DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N
Data - RECEIPT#
WORKMAN COMPENSATION DECLARATION, FIXTURES PER TRAP SCHOOL TAX Y_ N—
[]I hereby affirm that 1 have o lmu ate of consent d spytheure,or RECEIPT#
ce00,L.botWorkere'ComperuatIon lruuranceoracerti(kd ropythereof(Sec. GAS F.A.SYSTEM-1 tNCAOUTLETS PARK FEE' Y 'N
3SW,Lab C3
Policy It ' GAS-EA.SYSTEM-OVER MAI RECEIPT# -
Com any � BUILDING DIVISION FEES
�CertRkd copy la;6 herebyth the ed.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertUedropy lafiled with the city inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ` �V
dCOMPENSATION INSURANCE SEWER-SANITARY-STORM EA'200PT 'Date Recei t#
(This sectinoneed not becompleted i(the permit la(Drone hundred dollare
($1 I0)orle that
WATER HEATER W/VENT/UECTR ENERGY FEE N
I certify hat in employ
he any person
m nRh annex want cern perm t 1.subject
Issued,
I shall not employ any person f any manner m s to become subject to the WATER SYSTEM/TREATING
workers Compensation Lawn o(Cali(ornla.Date PAID
0 Z Applicant '
Z 0 NOTICETO come APPLICANT:If,after rs'Co this ationlceteo(ons ofthe
NEIN RESIDENTIAL PCMB, SQ,FG' 'Revel t#
F
should become forthwith
the Workers'Comp provisions
orthiomrmat s Lab be 1 TO' AL:
W N deemed
e m you must forthwith mmpiy with each provlsiow orthla Fermat shall be B I �^e
deemedrevoked.
W CONSTRUCTION LENDING AGENCY I I E
Z once ofthe wrk -
CL ]hereby ormFEE
f'hat there la a construction lending agency for the perform- TOTAL: EL , IC
orwhkh this permit is lasued(Sec.3097,Civ.C.)
L) O Lenders Name - t t. PLUMBIN
Iy 1- enders Addreae PTY, MECHANICAL,.P,ERMIT tt,>FEE`;: METH L
O W IcertifythatlieswreadthisappllcatlonandA tethattheabovelnformatlw
C is correct.I agree to comply with all city and muteynnimances and state laws PERMIT ISSUANCE FEES ISA
} W relating to building corutructlon,and herebyauthorize representatives ofthis `
E city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMBCH.
(We)agree to save,indemnify an d keep harmies the City of Cupertino Is e Receipt#
against 11 bNtles,#&groes ,coats end ezpensee which may In anywayaccme AIR HANDLING UNIT 0010,000 CFM). - BTOTAL
agal dCity con ance ofthe granting of this permit •
AIR HANDLING UNIT(OVER lo,"CFM) � CONSTRUCTIO TAX
re
Slgnamof Appllea 'ontractor �I •
aila I� ExHAusTHooD(w/DUCT) CONSTRUCTIO TAX-PAID:
HA7ARDOUSMATERIALSDISCLOSURE I lDr1G`
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 1001000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health end Safety Ccd�ction 25532(a)7 HEATING UNIT(OVER 100,000 BTUj TO
Yea.., o -
Will the applicant drfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$1pg
which emit hazardous air contaminant.as defined by the Bay Area Air
Ilty Mawgement Diaidct7 BOILER-COMP OHPOR 100,000 BTU)
Yes �INo P ,s _u 1MJ'{�
havertheta ar tyCodeialaregWrerrentsund and
6.95 of BOILER-COMP(OVER 100,000BTU) NO 1
the Californianla Health&Eatery Code,Sectlons?5505,75533 and 25536.] P1
understand that tithe building does not currently have a tenant,that it is my, NEW RESIDENTIAL MECH. SQ.FTTi4\O. z
pmu Bity to noKlythe ocmpaot of the requirements which must be met
p rr uan ofaCedi cafe ofOcc�parcy. CIIY
rLY�f
Owner rauthorizeda antISSUED BY:
TOTAL.
OFFICE COPY.