22239 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PERMIT NO.
Building Add.- "
/0699 �1AXII)o 950122239,
c I,o,ssa:% � y�./L,� on .
VL CITY OF CUPERTINO-BUILDING DIVISION A
C,qIWdorelyama: hQn LIe.No; APPLICATION /PERMIT
BUILDING-ELECTATCAGPLUMBING-MECIf LAICAL CATEGORY - CONTROL#
, ArcItect/Englnnr. Lie.No:
QTY ELECTRICPERMIT - FEE •BUILDINGPERMITINFO
Address: PERMITISSUANCE 1:1 El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(cormonee. APPLIANCES-RESIDENTIAL JOB DFSCRII'I70N
ingwlth Section 7000)of D)Vidon3 ofthe Buslnmsand Professions Code,and my
Ronnie In WI fora andPANELS t y
License Clam I.
N
Date Contractor —UP TO 200ANT5
ARCHITECTS DECLARATION 701-1000AMPS
Cy Iunderstand mypian.hallbeused aspublicrecords. OVER1000AMPS i n, FT. EA $/SQ,Fr.
Ie o`j Licensed Professional SIGNS ELECTRICAL /A/� �V I N
7 F Q y OWNERex rcpt Ire DECLARATION $I+pf]ALCRiCI1IT/MISC E 1/0 P U T E R
6 Ihereb affirm thatlam exam fromthe Contractor'sLlcense law for the
O
following ensure.(Section
sap7rrdtto Business and Professions Code.Mytllyir
a' countywhkh rcqulresa pertNt to amtmct,alter,lmprove,dennlbh,orrcpair TFMP.M=ORPOLEINST. '^^ —
M a anystructure pdorto Its lssuance,axerequirealAeappllont for such pernotto
V POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3 ec Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING]VIOL ELECTRIC
COs A.0oftheBuslnemand ProtembmCade)orlhathelseamptthemfromand VALUATION
6_ the basis for the alleged exemption. Any violation of Section 70715 by any OUILE7SSWITCFIFSHK7URE5
applicant fora permit aubodsthe applicant to a civil penaltyof not more than
five hundred dollars($500). NEWRESIDENTIALELECTR SQ.hT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sate
compensation,wllldothe work and the structure isnot intended or offered for
Oale(Sec.70K Business and Professions Code:The Contractors Llcerese Law
does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RFS UNITSCC.. who doessuchworkhlmselforthmugh hleownemployees,provided that such
improvements are not Intended oroffered for sale.If,however,thebuili ing or TOTAL:
improvement Bsoldwilhlnoreyearofcompletion,the owner-builderwlll have
t ,den of proving that he,did not bund or Improve for purpose o(aale.). QTY, PLUMBINGPERMIT FEE FLOOD TONEAPN
Lj I,as owner a(the property,am exclusively contracting with licensed PERMIT vLSUANCE
contactors to mrutruct the project(Sec.70K Business and Profamioru Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
heads or Improves thereon,and who contracts for such ptujecti with a
"�➢!(+ctar.)licensed P.meant to the Contractors License Law. FEE SUMMARY
L�I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Dace DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION REC77PTp
❑l hereby affirm that I have a artl0ate of consent to self-insure,or a FIXTURES PER TRAP SCHOOL FAX Y N
ani(IaWorken teofCompematlonlwurana as certified copy there.((Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK RECEIPT
FEE Y N
Polis # Cd
Policy p GAS EA.SYSTEM-OVER 4(EA) RECEIPT'#
Com any BUILDING DI VISION FEES
�certmed copy is hereby furnlahed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certmed copy 6 filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP ARY PAID ,
COMPENSATION INSURANCE
(TMssectlonnand not becompleted lithe permit lsforone hundreddolian SEWERSANITSTORM FA.700FT.. Date Remi t#
(SI 00)orlessJ WATER HEAT04 W/VENT/ELECTR ENERGY FEE Y N
IDcartify leshat N the performance of the work(.,which this permit b Issued, -
I shall not employ any person in any runner n as to become subject to the WATER SYSTEM/TREATING
Workers'CompcnsaHon Laws.!Californla. Date PAID
-
Z Z NOTICApplicaE
NEW RESIDENTIAL PLMB._5Q.FI. Date Remi i#
Z Z NOTICE TO APPLICANT:If,akar making this Certllate of Ex You
Fshould becomesubj°ct to the Workers'Compensation provlalons of the Labor TOTAL:
ir fA Coda you=at forthwith comply with such provisions.,this permit shall be
domed revoked. B DI
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction Lending agency for the perform- ELECTRIC FEE
Z ance fthe work for which this permit is heated(Sec.3097,Civ.C.) TOTAL:
U O Lender's Nacre PLUMBING FEE
LL ~ Lenders Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iiertllythat l have reacithbappliatlonand statethAtheabove Information
Is comet.I agree to comply with all city and aunty ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a relating to building construction,and hereby authorize representatives ofthis
I.. city to enter upon the abovernxmioned property for Inspection purposes. ALTERORADDTOMECH.
Z Date ROCeI f#
(We)agree to save,Indemnify an d keep harmless the City of Cu permo
ago at llabilltin,pdgmenb,coelsand expenses which may in anyway accrue AIR HANDLING UNIT(ED 10,000 CFM) SUBTOTAL:
a i bald try Io uence of the granting of thio pe it •
/D�1 AIR HANDIJ NG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
I to o(Appllant/Contractor C Data / IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR DOGS MATERIALS DISCLOSURE
illtheapph torfuture building occupant store or handle hazardous HF.ATINGUNIT(T010D,000BTIn
materlalasdefined by the Cupertino Municipal Code,Chapter 9.17,and the _ Date Recei t#
Heslthand Safety Calc 5ect1on25537(a)1 HEATING UNIT(OVER 100,000 RTU) TOTAL' Lj�(�
❑ Yrs �No ��,:
Willtheapplic.ud.,future building occupant use equipment or devices VFNIILA]TON FAN(SINGLE REND) ISSLIANCE=DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BO[LER-COMP OHPOR 100,000 BTU) �� ,1 0 �rC�
I?Yn n No *1 s7;+
a'Ya ad the bavJ� 000ecmla requirements underChe pter 6.95 of BOILER.COMP(OVER IOO,OOD BTU)
the California Health A Safety Code,Sections 25505,25533 and 75534. I
understand that lithe building does not currently have a tenant,that It he my NEW RESIDENTIAL MECH. SQ.I.r (sj4aa Yl asf cupt(a#q
responsibility to notify the occupant of the requirements which most be rt Rwr llmCw
prior to Issuance on Certificate of Ocavpanry.
Owner or authorised agent Data - ISSUED OY
TOTAL:
OFFICE COPY
— r�