22144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY .
Butiding Project Identification PERMITNO. '
Burlding oo k. lhek,071A -[ IMLeV 22144
nein ane: �3 /� none.
CITY OF CUPERTINO-BUILDING DIVISION
r ConhactoreName: Lie.No: APPLICATION I PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CDNTAOL 0
•'rchitera/Engineer. Lie.Na
-'
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Addrcsa:
LICENSED
\CFCONTRARODECLARATION
PERMITISSUANCE
I hfirmthat Ia under provisions
neolChapter9(mmmrnAPPLIANAPPLIANCES-RESIDENTIAL JOB DESCRIPTION❑1lON
ing.ithSamon
ofDiat.1o3.4th.BuslncestandProleaYamCode,and my
Iice...s..n full forceand effee.
❑
PANELS ' ^—R.CI U �V��
LlcenseChss LIeM '
Date- Contractor UP TO 200 AMPS -
ARCHITECT'SDECLARATION 201-1000 AMPS '
00 f understand my plana shall be used as public records. OVERI000AMPS SQ.Fr.FLOOR AREA - $/SQ.FT.
tt I Licensed Professional SIGNSELECTRICAL ' -
<<�.4 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M69C Pj
7 t.rC-ia Ihereby a(0rm that l amexempt fromthe Contradars License law for the
p pp following reason.(Selo.7031.5,Business and Profnslons Code:Any city or
FZf'W countywhich requbd.a permlttomrutrud,alter,Improve,demolish,orrepair TEKP.METERORI'OLE INET.
6� anystmu mpriortoltalsmance,WomquimsiheappRcantfonrtuchpetto
P Q Ole-signed statement that he b 11...d pursuant to the provbiom of the POWER DEVICES' �J
6W Con/nRore Liodue Law Cha erg mmn¢ndn with Section 7000 of Dlvl- f_
3wp In ( ss ( R ) SWIMMING POOL ELECTRIC _ -
�
ii
thex10basis for
the alleged exemption.
exemption. Any violationhat of exempt therefrom and ALUA N
Q the Wab for[he alleged exemption. Any violation of Salon 7011.5 by any OUTLETSSWPTCFIESH)(ITJRFSI , O mays s.
appllantfora paced[subjectstheapplkant ton dWl pemlty door nnrethan VV , -�
five tutdred doll..(Mail).
LJ 1,as owner of the NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPECONSTRUCTION
property,or my employees is with wages as[herr dole
campensatlon,wllldothework andthe etmdurebna intended or offered for
M dale(Sec.apply
to ainowandf property Code:The Contractors Uceme Law
�j j$ does not apply torn owner of property who Wilds or Improves thereon and OCC.GROUP RES.UNITS
CC:: whodoc=tawork hlmdeUorthwgh his own employees,howeer,thedthat ildingh
improveng ars,norIntended
neyearfoomfor aak.theowevepthebuRdl have TOTAL: -
ImprovemeyyMM+e�oldwithin one yearofcompldbn,theowner-W Bderwlll have
tlgjxh�egofproving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
�L( 'L as owner of the property,am exclusively mntrading with licensed FLOOD TONE APN
contractors to construct the project(Sec.7096,Business and Professions Code: PERMIT ISSUANCE
The Contractors.License Law don not apply to so owner of property who
buALTER-DRAIN&VENT-WATER(FA)
Wild. or Improv.there
on,and who contracts for such projects with aFEE SUMMARY
op ador(s)Bmn ed pursuant to the Contractor's Llanse Law, BACK FLAW PROTECT,DEVICE
_ Ll l a exam arrear Sce. B k P C far t is renes. OUTSIDE FEES
t -Y Own r n D NS FLOOR ROOF,AREA,COND. SANITARY � Y N
Data RECEIPT M
WO N COMPENSATION DECLARATIOI FIX PER THAT SCIlOOL TA)( V N
l ❑I he a(f m th t I have a ceMfate o!consent<o sal!-insure,or RECEIPT N
m.i(irecolWor peruation lnsuwnce ora certified mpythemo!(Sea. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE 'Y
3800, N
Lb C.) RECEIPT
Policyp GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DI VISION FEES
Certified copy I,herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b(Pled with the city Impectlan division.
CERTIFICATE OF E(EM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMG 200PT Date Recei IN
(This section need not be complded Bthe permit isfor one hundred dollars
(8100)alre.I WATER HEATER W/VFM/ELECT[[ ENERGY FEE Y N
Iadify thrt In the per(Cmanaolthe work(orwMch this permHb Wued, —
I.hallnote loy enyp ion In any mannarro act pq ubjed to the WATER SYS.ILN/.1RFA.ITNC PAID
Workcrs'Co nsallgp} w of II(ornla.Date _1 _
ZZ Applicant NEWRESIDENTIALPLMB. SOFf. aft Recei tN
Q NOTICE TO LICANT , Ter making ertBlrate of Exemption,you
rshould become bjeet to a orkars'Compematlonprevielomofthelabor TO L:
N Cade,you must orthwlth ly with ouch provielom orthis permit shall be
W CC 7 deemed rcvoked.CONSTRUCTION LENDING AGENCY S MIE l
a Ihermyaffirm that there is a construction lending agency for the perform- E 'CTRIG FEE
Z ante of the work!or which this pemJLLislssued(Sec.3097,Cw.C.) TOTAL:
00 Lender.Name. PLUMBING FEE
ly F Lender,Aaarea. 1'4e QTY MECHANICAL PERMIT FEE • MEC NI L E
OW Irrect.I agree
to comply
with
alicatlonandataty ordinances
S La correct.]agrecto comply wllhalldtyaiW county ortlinanocaand state lawn PERMIT ISSUANCE FEE
N relating to building comtructian,and herebyaushodaa representatives of this
city to enter upon the abDocmentionad property for lnspedlon purposes. ALTER OR ADD TO MECH.
2 (We)agree to save,Indemnity an d keep harmless the City of Cupelno Receiptp
V against llablllties,judgments,me,and expenses which may in any way accrue AIR HANDLING UNIT(17010,000 CFM) BTOTAL:
a aire`aald ley In mnsequence of granting d this permit -
(c L /' I AIR HANDLING UNIT(OVER I0,000CFM) NTAX
SI ature of pBcant/Contractor �y L/f'p to _I EYHAUSTHOOD(W/DUCD O NTAX PAID:
HAZARDOUS MW1713RIALS DISCLOSURE
Wlllthepp mntorfuwmbufldingar pantstomorhandleha rdous HEATING UNIT(TO 100,00)HTU) RC[ei [q
muterlalm f ed by the Cupertino Municipal Code,Chapter 9.12,and the
I fralth and Safety Cade Section 25532(x)7 HrATINC UNIT(OVER 100,000 BTU) TOT L: 7 L'
OYen M No
Will lheappilant or fmirebuild -pant use equlprrent or devices VENTILATION FAN(SINGLE RESID) I SUA E
which emlt haaardou.air mora nba dined by the Bay Area Air /(V �
a \ Quality Management Dierl BOILER-CAMP p7-0r OR 100,000 BTU) nr
Yrs o - �
i' Ihavc read the ha>a oars rrulerlala requlremenfs under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �a,.
the understand
that
O afetybuilding
Code,not currently
ntlyh have
a tenant,
255X.1 y�yGyfli/U-
'ry' the CaltzraltI alth building Coda nmtions 25505,25533 and 2553411 Is my NEW RESIDENTIAL MECH. SQ.Fr. dJ1('fLnApis'.(a1`a
responsibility to naify the occupant of the requirements which resat be met ♦?
prior to uanceofa dificat ofoccapancy.
M �
Ow.4 Nuflb.,Wd�hnt ate ISSUED g��r�
TOTAL:
OFFICE COPY