22295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE'BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Addmm: O 0 ,� 22295
C
wee s � one:
CITY OF CUPERTINO-BUILDING DIVISION
� Contntr,is Name: Lie.Nm APPLICATION / PERMIT b
' ArchltM/Engineer. sS^ oIo o- BUILDINGELECTMCA nUMBINGMECIIAMCAL CATEGORY CON 'SI3b
OTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
CJ
Address PERMIT ISSUANCE `�f'
LICENSED CONTRACTOR'S DECLARATION
ffirm Best wilco oftheunder Busimprovisions ndPm Cnions9(commrnc- APPLIANCESRESIDENTAL JOB RB'TION
Ingwlih5sctlon for,, Dlvle�oa3otthe Buslnessand ProleulonsCode,and my p� a-•a
license is
for,, act. PANELS
License Clea LICM n
Date Contractor TO 200 AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
X I understand my plane shall be used as public records. OVER1000AMPS SQ.Fr.FLOOR AREA 9/SQ,FT.
OCC
�(2 Licensed professional SIGNSELECTRICAL -l."L(, $ 1 2
fEAy ( 'C t
OWNER-BUILDER DECLARATION
5['ECALCIRCNT/MISC
ZF, owing reffl.ason.
coonat I 70315,exempt from
ossa d Professior.ns
Code:
Law cotton
followingreaean.(imap7 twcuclnen anter, fp oneeml:hormpir
' O TEMP.METER OR POLE INST.
F�ppppp tvuntywhich ruqulreea pernJtrocowtrucl,aller,lmprove,demolish,arrepalr -
�< .a anystmcture printer,ltslexuence,also requlreatheappllant forsuch permit to POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
Ou, Contractor's License iew(Chapterg mmencin with Section 7000 o(Divi.
Iei.n3.fthe SuelneuandPr mmom Code)orthatheiscumptthemfmmand SWP4MING I'bOL ELECTRIC VALUATION
G�q1 S° the balls,for the alleged esemption. Any violation of Section 7071.5 by any rfM. ] e-a Qa G
Ga « appllnntfer apears($5bjets the applicant too civil penalty of nor more than OUTLETSSN77CHES-F7XrURES lX/ D yl
live undrcd dollars(f500).
NEW RES[DEKIlA1,ELECTR
..�n I,as owner of the property,or my employees with wages as their sole —e'Q'F r. STOEES TYPE CONSTRUCTION
com(Sec.7 Ktheildotheworkendhm,Codure brat Intended oroffered for
k vie(Sec.apply
to an owner
property
Code:The Contractors improve;Licenstheme,and
does ratapply toanownerofProperty who nemporlmprwestbereoryand
6
who daeesuch s work am
Intended reoffered
his owne.If,
providedhowever,
the build
thatIng or
improvement are not Intended oro(fered fonale.](,hawevep ihebulltling or TOTAL:
I improvement bsold within oneyearo(compldtW theowner-builderwlli have OMP U
tl)gJ(urden of proving that he did ns,build or improve for purpose of sale.). QTY, PI;UMBIHG"PERMIT FEE.' HppD pp �I
n Sae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ��aEY.T� TE
contract'"s construct the project(Sec 7044,Business and Professions Code: t�saa.,
The Contractor's License taw does notapply to an owner of property who ALTER-DRAW kVENT-WATER(FA)
builds or Improve thereon,and who contracts for such Imjem with a
gq5IlIT.c1cr(e)licensed pernment to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
el—I l am exempt under Sec, B h P C for this reason
Owner DRAINS.FLOOR RODE,AREA,GOND. SANITARY Y N OUTSIDE .
Date RECER'T'M
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP r1'V SCHOOL TAX Y N
❑I hereby affirm that I have a cetl0cate of consent to epythcore,ora IX/ RECD.N
cenlBnteofWorkeri ComperwHon lruunnce ora m"f copyihemo((Sec. GAS FA.SYSf7M-1 WC.40UTLETS
Poll; C.) - rj �® _ PARK FEE RFLEIPT
Coma d GAS EA.SYSTEM-0VER4(EM BUILDING DIVISION FEES
ertif"fled copy bhedwithreby le cityad. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certitled copy b toed with the city Iwpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID G -1-0't I b L�
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 20017, Date Recd
(rob eectlonneed rat hcomplied lithe permit bforces hundred dollars Pt4t L37_
(8100)rtifyt3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icenot tbatlnthe person In nce
the week so as tobcowhich mesubjermit bo theed, a� —
Woall not employ any person In any manner se u to become robjat to the WATER SYSTEM/TREATING s
Workers Compensation Law.of Gab(omb. Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date Recel t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of P.xempilon,you SQ.FL
Fshould become subject to the Workers,'Comperxaatlon provbionsoftha Labor TOTAL:
CC 0 Code,you moat forthwith comply with such provedoes orthb permit shall be
j deemed revoked. 'E
W E CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Il Thereby al0rm that toereb acowtmction laedingageacy for the perform- TOT L!
ELECTRIC FEE
7 Z ancooftheworkforwhlchthb pc meltlabsued(See.3097,Cie.C.) a
U O lender'sNamn PLUMBING FEE e
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WlcedifythatlhavemadthisappBcalbnanda thatthe above information
bomead.I agree to comply with allcity and county ordinancesand pate laws PERMIT ISSUANCE FEESPAID:
} O' relating to building commotion,and hereby authorize representatives of this CV
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADD TO MECH.
_ (We)agree to save,Indemnify and keep harmless the City of Cupertino Dale Receipt!!
ago WtllabNtles,pdgmenta,meta and expenses which nuy In anyway aatue AIR HANDLING UNIT DO 10,0DO GEM) SUBTOTAL:
a told City In ronaequenceo(ihe gracile of Iola permit.
AIR HANDLING UNIT(OVER 1O,MCFM) CONSTRUCTION TAX
geamreof Applinnt/Contractor Dol EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous BEATING UNIT(TO 100,000 B'Hn Date Revel tet
ma rlal as defined bythe Cupertino Municipal Code,Chapter9.12,and the P __
ITulth and Safely Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
I-1 Yes p]No -
Illtethacainntor`cont building occupant use the Bay Area devices VENTILATIONFAN(SINGLE RESID) ISSUANCE DATE
which eMa ha gement air contaminants ante as de0ned by the Bay Area Nr L
Quality'ra.d the
ha e[ No 001LF.A-GDMP(3HB'DR 100,000 BTU)
4 Yea 4 No
have la lealth ar nus materials reons 255nbundeand 2554.1 of BOILER-COMP(OVER 100,000 BTU)
g the understand
Healthk buildafetying
Code, orcu e25505,b5 tenant,
75534.1 I
undcrtandlhat if the building don rat arrently have atenant,that itbmy NEW RESIDENTIAL MECH. SQ.IT.
rnpomibllityto ratify thcotvpant!the requiremeniawhich must be trot V i s,7
prior m]nuance of a Cetitinte of Occupancy.
Owner or authorized agent Data ISSUEDBY:
TOTAL:
OFFICE COPY