22973 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ert Identification PFRMITN'O.
Building
lo t Zd 22973
ere a
9LD•ZS$• S CITY OF CUPERTINO-BUILDINGDIVISION—
APPLICATION / PERMIT- - G Ir 4-0
1
417—Fib BUILDING-ELFCTRICALPLUMBINGMECHANI AL CATEGORY CONTROL X
iter/Engineer. Lie.No:
QTY ..ELECTRIC PERMIT .FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE —PLUMB MUCH
1:1 LICENSED CONTRACTOR'S DECLARATION
Ihehsyoi.lrmthat laiW.i.3licensed under
e.Busiprovisions dPm Chapter9(emmrnc APPLIANCES-RESIDENTIAL JOB DESC ON
Bonn.hSenl�of UWfect. the Buclneasand PmfnslonaCode,and my w
LJoe 1.1.full and effect PANFIS
Lice CI Lt.#_
Date •k _Contr ills,
—Up TO 200AMpq
ARC RATION 211-1000 AMPS
pw�7 understand'mfes my phre shall be used a public records, OVER SIGNS
E ECTRI5 SQ.Fr. PAL$ISQ.k� LirensedProfemlowl SIGNSELECTRICAL OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC I hereby affirm that Iaro exemptfmm the Contrador'a License Law forthe afollowing resson.(Section 7031.5,Business and Professions Code:Any city or. hlchre 1 mat to..truci,alter,im edemolb orrepair 74pP.METQ(ORI'OLE INST.stm quroea pe prow, hanyassignedpde entehat a Isalsosed pursuantt the rovisions of t e POWER DEVICES0Ie a algned statement that he b limned.pursuant it the Pon 7X0) of the Cor3oft a usinr eLaw(Cfa.t 9(rommencing thathebemmonherefo(Dlyl-
SWBr(MINCR70LLLGCTRICslothe Wisf.,thlncaeandPfession. Any)iolati n ofSecmpt therefromand �+�'�the balls fur the alleged exemption. Any violation of Section 7W1S by any OUTLETSSWITCHESFIXTURES
appE=tforapert tsubj lstheapphcanttoadWipenaltyofnmm mthan l3O vat✓
18Pfive hundred dollars(SSM.
[. �n ❑I,as owner of the pros property,or my employewith waged thele dole ' ' STORIES TYPE CONSTRUCTION
r NEW RESIDENTIAL ELECTR ��
compensation,wfildothe work,and thestructurs is nor intended offered for
P O sale(Sec,7044 Business and Professlov Code:The Comractota Licemelaw `7^
0;2 does not apply to an owner ofproperty who Wilds or Improves thereon,and - OCC.GROUP RES.LINTS k—
whodoessuchworkhlrroelforthroughhisownemployees,provided that such _.
Improvemcntsarenot intended mattered forsale.If,howeverthebuildingor Tp Ia I
Improvement,.sold withmoneyearo(completlon,the owner-bullderwillhave
t"rden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEB
LI FLOOD TONE. APN
1,as owner tr the property,am exclusively ag.and
with],Coal. PERMITISSUANCE 1
TheconContract Crewcitheproject(Sec.appy to peas and of property who L
The Contractor's impro e.thennse Law aces not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereun, and who Cntracte for such plokm with a
cg0.t.[actor(a)Ilanecd pureuant to the Contnctor'e LirenaG Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Sec. e k P C for this reasonOUTSIDE I
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
' Owner Date RECEIPIR
WORKMAN COMP L'NSATION DECLARATION FIXTURES PER TRAP as� SCHOOL TAX Y N
QI hereby affireatorkem that I have o certificate of consent to opytheure,ora RECEIPT Y
3800,cediflLab o(Worken'Comperaatlanlmunnreara rerti(kd Cpythereof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
Policy
Lab CJ
Policy RP.CEII'T p
Com an GAS EA.SYSTEM-OVER 4(EA)
Y - BUILDING DIV]SION FE ES
Certified copy is hereby tGREASE/WDUSTRL.WASfE INTERCEPTOR PLANCHECK FEE
� e
Certified copy b filed withh the
hthe city
Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS• CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMfARY-STORM EA 200FT Date Remi tp
(T m lectlan need not be completed If the peroat b(or oro Fundrcd dollar.
(81I centless,) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl(ythat In lh m ranee of lh ork farwhlch this permit bbsued, —
sI shag not em 1 ere 1 any n er so o��gm0,pi�ject to the WA.I.Cti SYSI,PM/.I.RG.DNG
Worker% slaws Catlfor Date 11•IS�-J PAID
0 Z Appli NEW RESIDENTIAL PLMB. SQF. Date Remi tN
Z 0 NO 1 . , gl'flee nukinZertNote of Exemption,you
should Womnesubto the Warken'Compensatlon provisions of the Labor TOTAL:
LU FEE
M W Code,you most forthwith comply wlthiuch provbiora orthls permit shall be HUIL j deemed revoked.
LU
G' CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is censtmetlon lending agency for the perform- T `� ELEC-FRIG FEE �e
aa,.f the work for which thin permissuedC.)
it is (Sm 3097,Civ.
U O Leader's Name PLUMBING FEE !•
LL I— Iendare Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mettlythat l have read thbapplleationand statethat the above informationomect I agree to complywith all city and ommyorrllnanCa and state laws PERMITLSSUANCE FEES PAID:
a relating to building Cre/ruRlon,and hereby authorize representatives of this
W city to enter upon the above-mentioned property for inspection purpose. ALTERORADDTOMECH.
? 4mterialasdefined
tc ave ademnlfy end ep harMess the Cily of Cupeaino Date Remip[ri
V s, d sin slsand xp sea which may In enywayaccrue AIR HANDLING UNIT(f010,000 CFM) SUBTOTAL:
1 d sof the ra ningofthiapernotQAIRHANDLINGUNIT(OVER10,000CTM) CONSTRUCTION TAX
t/ ontncior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCLOSURE
ll nt future building oavpentstore or handle hazardous HEATINGUMT(TO100,000BTU) pate Rmei tM
ed he Cupertino Municipal Code,Chapter 9.12,and the -
lieaithand 5afMy Cade Section 2S532G)7 HEATING UNIT(OVER 100,00(i BTU) TO
❑Yea n No
Will the applicant or forum building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP LIFE'OR 1(X1,000 BTU) .
4 Ye d No
have read the h. us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) /\
.the Celifomlai-Iifthh s ildityCode,Sertiona255p5,25533and25534. I PAID
s a, �/��/•1"�'�/\
uer-alandthallfthe1,Safengdoes Scars 25505,25533 and,that25534 itlsmy NEW RESIDENTIAL MRCFS. SQ.FT. Ip \V\V�/'•'i✓'
responsibility to notify the ocapa at of the requlrerrents which must be met
prior to issua ace of a Certificate of Oreupan y. NO
Owner or authurlud agent Date
TOTAL: ISSUED
OFFICE COPY U