22759 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 1 - _ 1 / C PERMITNO. -
Building Address;: W\ Ol \N 22759
.-
t: L cZ SS^(O
nereName: one: 79PPOZ7 A
CITY OF CUPERTINO-BUILDING DIVISION _ �^— Cj
c°nt^ttwsName: _ Lie No: APPLICATION / PERMIT — Iv [
BIIfLDINGELFJCTRICALPLUMBINGME LAICAL CATEGORY CONTROL N
Architect/Englneer. - Lic.No:
Cry ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 1.7 - PERMIT ISSUANCE 1:1 ❑ ❑
LICFNSED CONTRACEOR'S DECLARATION
I herebyafflrm lhatlam licensed under provisions of Chapter9(mmmenc. APPLIANCES-RESIDENTIAL , JOB DFSCRETION'
ingwith Se"Ion7OW)of avision3ofthe Businemand Pmlessions Code,and my
license ifell and effect. PANE7 9
License Claw
Cbss Liec
Date - Cmaracter LX 10 200 ANIPS
201-1(00 AMPS
ARCHITECTS DECLARATION
n4 7. I understand my plans shall be used as public records. ' OVER I000 AMPS SQ.IR.FLOOR AR S/SQ.Ff.'
u�O
O
Licensed Professional SIGNS ELECTRICAL
�< .OWNER-BUILDER DECLARATION 5, SPECWLC1RCUfT/MISC
Fo, a Ihereby affirm that l am exempt from the Contranorb License Law for the
] ^ following reason.(Section 7031. Business and Professions Code:Any city or TEI✓.1+,MEIPROR POLE INST
u� county which requires a permit to construct,alter,improve,dennLLsh,or repair .
_
S ,4�_a anyslm=mpr rloiol amaLsorequ4.theappllantforsuchper tto POWER DEVICES
0.V file a signed statement that he b ron licensed pursuant to the pvisioof the
Contractors License Law(Cha er9Comnandn withxemptthenefof Dlvl- S�VALIJATION
Ell
Cmitro Rhe Business and Professions Code)orlhnghe la with Section
l7")of and SWPIMINGIVOL ELECTRIC (////11 Va
i 6 5 the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETS-SWITCHES I O appgeant force permit subjects theapplican
no.civil penalty ofha morethan
five hu dollars($S M.fthe SQ.FT. - ES S '1ON
Tier NEW RESIDENTIAL ELECTR STORIES TYPECONTRUCI
property,or my employees with wages as thele dole
%a
compensation.7'ion,MltdotBusiness and
Perand iono,Code:
nor Intended orofferedl w - -
0 sale(Sec.apply
to Business and Profession Code.The Contractor's License law
(jS$ docs not apply torn owmrdthroug his
em orles,pro provided stand OCC.GROUP RES.UNITS
C.
who dons
mentsa not Intended
d own for ask.
If, ots,proviebulldtmce
improvements in irsone earofrempletlle.If, owner-builderwill have TOTAL:
Improvement bsold withlnoncycamfcompletloRthe owner-bu0derwl111uve -
thiLtIorden of proving that he did nen Wild or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed FLOOD LANE APN
contraction to construct the project(Sec.7054,Business and Professions Code: PERMIT ISSUANCE
The Correa ri License Law does not apply to an owner of properly who
Wilds or improves thereon,and who contracts for such plloje with a' ALTER-DRAIN&VENT-WATER(EA)
FEE SUMMARY .
�q6S(+ctor(s)IJ sed pursuant to the Contractor.License Law. BACK FLAW PROTECT.DEVICE
LJ[am erupt under Sec. B &P C for this cease.
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
Owner Date RECEIPT 0
WORKMAN OM EN ATION DEC
LAR ION FIXTIJRFS PER TRAP SCHOOL TAX Y N
Of hereby affirm that I have a artiRate of consent to self-i^eure,ora RECEIPT certificate ofWorlixm�Compensation insurance,or a certified copy thereof(Sec. GAS EA.SYSTEM-1 WG.<QDILEIS PARK FEE Y N
Policy
moulWb C.) - RECEIPT If
Polity p GAS EA.SYSTFbt-OVER 6(FA)
' Com any BUILDING DIVISION FE ES
ffCettlfied copy Is hereby famished. GREASE/INDUSIRL WASEINTFJLCEPIY3R PLANCI-IECIC FEE
Certified copy is filed with the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS.
• GREASE TRAP PAID -
`COMPENSATION INSURANCE SEWER NITARY-STORM EA 200FT Date Recd t#
(Thissectiooneed n°tbemmplat ifthepemdtbfwomhundrcddollan
($100),olean.) wA 7pRwh'FrT/EE:ECTR II, 'NERCY FEE Y_ N
Icertifythat In the performance of thework t°rwhlch this permit is Issued, . Y__
N_
shall not employ any person in any manner so as to became subject to the T� SYS WA /TREATING) �—
WorkerV Compensation Laws of California.Date �.'� I� AID
0 Z Applicant NEW DEN'IIAL PLMB. Dale Recti L#
Z O NOUCETOAPPLICANT:If,after making thisCertificate of Exemptlon,you
should become subject to the Worken'Compensation provIslom.Rise Labor TOTAL:
H stat Code,you must forthwith comply with such provisions or this permit shall be - p
CC j domed revekea. - 'Btii' DING FEE
W - CONSTRUCTION LENDING AGENCY - SEISMIC FEE
d ° Ihereby af0rm that there Is a construction lend Ing agency for the perform ELECTRIC FEE
7 Z once of the work for which this permit is Issued(Sec.3097,Civ.Q TOTAL'
U 0 Lend Wit Name - PLUMBING FEE
LL �- Lenders Adders. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W panRythat l have read lhbappBcathnand slamthat theaboveinformation
Isrorer".Iagreeto comply with allcilyand county ordi.a^cc turd state lawn PERMIT ISSUANCE TEES PAID:
d.
} relating to building conswction,and hereby authociae mprex^tatives of this
N city to enter upon the above-mentioned property forInspection purposes. • ALTER OR ADD TO MFCH.
Z
(We)agree to save,Indemnl(y an d keep harmless the City of CupertinDate Receit#o - P
V Iml tin,' d n,—...dc. .whichma in.. a cane AIR HANDLING UNIT 10,000 CFM) _
ago r Br^e^ Pe^ r rw ra SUBTOTAL: ST
again aid Ity In ronsequcnco of the grantit is permit.
AIR I-uNDUNc uNrr(OVER 10,000CFM) CONSTRUCTION TAX
Signe o Applicant/Co to or - Ding EXHAUST HOOD(W/DUCb CONSTRUCTION TAX PAID: `
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,010 BTU) Date Receipt#
material as defined by the Cupertino MueldpaI Code,Chapter 9.12,and the
Elealt h and Safety Cod a Settle.2S532(a)E r HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes MN.
Will the applicant orfumreWildingramufont useequlpment ordevlces - VENTILATION FAN(SINGLE RFSID) ISSUANG&�1TE
which emit ham rdous air cora minants as defined by the Bay Area Air - I �F"''rAM
Quality Management District? BOILFR-COMP DHPOR 100,000 BTU)
4Yes1�No
havercait the haraQusmaterials mqulrerrcntsunderChapter6.95of BOEER-COMP(OVER100,000BTU) SEP 1 1991
the Califwnoils.lth&Sfety Code,Sediom25505,25533a^d25530.i '
understand that if the building don not currently have a tenant.that It a my NEWRESIDENTIALMECH. SQ.FT /.
responsibility to notify the..poor of the requirements which must be melt C/{{b,at I�U�".1
prior to Issuance ofd Cerliticate of Occupancy. AAss I-
Owner or authimard agent Data ISSUED BY: L� ��xa—
TOTAL: I.
OFFICE COPY