22821 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY.
r
Building Project Identification PERMIT NO.
Buildiag Address: - - 22,821
fiat
nae:
wnars PL,= CITY OF CUPERTINO-BUILDING DIVISION. .. /b^/1,�•1 .
ContractortyName: 10 Lic.N. APPLICATION I PERMIT .
[�' gineneer.Qs BUILDING ELECTRICALPLUMBING MECHANICAL CATs- BY COC763
ArcMtect/Engineer. ' Lic.Na
'QTY�j,••j ` EGBCTRiC•PERlviLT' '::'F$E � "�':i,B,4JIGDING PERMI'I[/NF4
Address: _ PERMITISSIIANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that[amlloomed under provisions of Chapter 9(ournment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing ith5ecdon7000)of Divlsim3ofthe Businemand PmfesslonsCo ,andmy
license is In full force and effect. - PANE]S
License Cie. Lk.#
Date Contractor''
ARCHITECTS DECLARATION 221--loDoAmpsix 11 Ali] _U
�9; I understand my plans shall be used as public record& OVER 1000 SQ.Fr.FLOOR AREA $/SQ.Fr.-
Fi o Licensed Professional - - -- SIGNSELECTRI a �L®
OWNER-BUILDER DECLARATION SPECIAL CIRC + s�7 F
f., lherebyafflrmthatlam exemptfromthe Contractor's License Law for the I/
Z p2p" following reason.(Section 70313,Business and Profession.Code:My city or •-
02"'Q TEMP.METEROR iN411INST.
r cauntywhlchrequlresaper wcoma c"ter,lmpmve,demolbh,orrepalr „ 1 t {. .
q 7 anystrurnsre priortofsissuance,also requlrestheapplicantfm such perm(tto POWER DEVICES v Lw.
P,�G file a signed statement that he Is licensed pursuant to the provisions of the -
3u'I. Contradoes License Law(Chapter 9(commentlng with Section 700B.f Divi- SWIMMING POOL ELECI&C
sion 3 of the Business and Profeasloru Cade)orthat he b exempt therefromand TIO
y� .••7777 the task for the alleged exemption.-Any violation of Section 7031.5 by any OUTLE75SWITCHhS FS
0 appBcant for a permit subjects the applicant to a civil penalty of net more than (v�
five hundred dollars($SM. SQ.Fr. � STORIES TYPE CONSTI2UCT10N
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTR'
p perty,orhe employees r their
compensation,Business
and rkandthes Codureh�Contrended License Lw t
O, sale(Sec 7014,to ainowandf property Code:The or Improves
sUreeon law
$ does not apply to an owner of property Me o builds or improves thereon,and
�$^
who doeaeuchworkMmselforthrough hiaown employees,provided that such -OCC GROUP RES.UNITS _
improve menti are not intended or offered for sale.If,however,thebuilding or .,'TOTAL:
improvement issold within omyearofcompldiorytheowner-bu0derwfllhave
tliakurden of proving that he did not build or improve for Purpose ofa le) (j1'..1.. tt�'.isLU7YiBINt.':iMERMiT t, ,1 11•iF'EESt" p)ppD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to rowtrud the project(Sec.7044,Business and Pro(essima Cade: ..
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for such ptofects with,
coactor(e)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICEti-:'." 1+:''FEE:SUMMJ�RY:'
IJ I am exempt under Sec. g k P C for this reason
'.� DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y " N Owner Date RECEEp
WORKMAN COMPENSATIONDECLARATIONto sN .I.0PER TRAP SCI{OOL TA% Y_-N
❑I hereby affirm that I have o certificate of consent to seythemof ore _ RECEIPT j7-
certificate o(Workers'Compewatlonlruurance oracerti(Ied ropythereof(Sec.3800,Lab Q GAS-EA.SYSTEM-1 WC40UMETS - PARK FEE Y "N
BBC=N
.
C # GAS.EA.SYSTEM-OVER4(0A)n BUILDING DIVISION FEES
C ffC e - .Certl(led copy bhereby(umlehed. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECKFEE
�Cedifled copy b filed with the city inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP J5. '' PAID &'�A
COMPENSATION INSURANCE SEWER SANITARY SCORN EA 7IOFP Date Rec'e'
(Thissectionneed not becompleted lithe permit bforone hundreddollara ,
($1I cemless.) WATER HEATER W/VENT/ELECTR ENERGY FEE N
I certitytha[N the performance of the work(&,which this permit is issued,
I shall not employ any person In any manner so m to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of Czhtorela.Date PAID
C) Z Applicant NEW RESIDENTIAL PWB: SQ.hT. a R 1 f#
Z O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you
should became subject to the Workere Compensation provisions of the Labor O AL:
F N Cade,you must forthwith comply with such provlsloret orthis permit shall be
LU > deemed revoked. - BU1 IN
IL c CONSTRUCTION LENDING AGENCY SEIS IC
Z thereby affirm that there is a construction lending agency for the perform TOTAL: ELE FEE
M O ance of the work for which this permit is heated(Sec.3097,Civ.C.).• t
L) fender's Name PLU ING FEE
ly I— Lender's Address QTY :•`'', IYfECEfANICA4''PERWIITS s};YFEEt; MECHANICAL FEE
If
O W Icertitythat]havereadthlsapplicetl.nand rtatethaltheabovelniormati.n - �.p�
.a Is correct.I agree to comply with all city and county ordinances and state law. PERMITISSUANCE FEES PAID:
>. W misting to building construction,and hereby authorize representativesofthis W_ - Sew ~'
[— city to enter upon the above-mentionedZ property for Impaction purposes, ALTMORADDTOMECH.
? Me)agree to save,Indemnify an d keep harndess the City of Cupertino - DB[e Rec t#
against liablli ajodgments;"sand expenses which mayinanywayaccrue AIR HANDLING UNIT CFO III=CFM) tTAPAID:
against 1 Inc saryen aqf she granting of this permit.
/ .c ova HANDUNC I1MT(OVER IB,aoocFnt) CONSTRUCTIO
P CONSTRUCTIOSlgndlureofAppBcant/C dor = C� IXHA(157 HOOD(W/DUC77HAZARDOUSh TE RIALS DISCLOSURE
Will the applicant ortuture building occupant store or handle hazardous HEATING UNIT(TO 100,W0 BTU) Da[e.material as defined by the Cupertino Municipal Code,Chapter 9.12,and theI kalth and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,1100 BTU)
' ❑ Yea NN. -
Willtheapplicantorfmein bullding.eevpantuse equipment.,devices .VENTILATION FAN(SINGLE RESID) .i. ISSUANCE DATE ,
which emit hazardous ale contaminants as defined by the Bay Area Air
a lality Management DisMct7 - - B0ILER.COMPDHPORI00,0WBTLn • ^ -
I' I Yca 9 Na „n Y
7haread ealthhe a et materials requirements 5,2553 and 25534.
1 of BOILER-COMG(OVER 1(10,000 BT(1),he Uy
un Californiatandt Health buildingthe Code,Sectionsedyh ve at and2539.I - ULf( )0 I
understand that notifytheoup.rt not a requirmnt,tenant,that it is NEW RESIDENTIAL MECN. SQ.FT. 1 g
responsibility to Issuance
ce notify the occupant of the requircmente which must be met Ply.
prior to tssuanre ofaCertificate of Oeevpanry. k� - -
sa.�!�jJfIIftJ@
Owner or authorized agent - Data -
TOTAL: ISSUED BY:
OFFICE COPY