22530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPro ed Identification PERMIT NO.
B°B�5o sT6Lt�sTk . 22530*-
5 rwp �(�-.
OwnersName: one:
" CO IA n—$87 CITY OF CUPERTINO-BUILDING DIVISION
cono-act.ra Namr: LIe No; APPLICATION / PERMIT O'
• /y01 ;r �GTop BUILDINGELECTRICAUPLUMBING-MECHANICAL CATEGORY CONTROL �
/ ' L
Arch[red/Engineer. Lie No: C YJ
xoml,JI I"4lt'11b Q - �BUILDING PERMIT INFO
/— QTY ELECTRICPERMIT FEE
Address t10 ;?$_
pERMITIS[fANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrm that lam licensed under provisionsof Chapter9(rommmc. APPUANCESRESIDENTIAL ]OB DESCRIPTION
ingwith Section7000.f Dlv[eian3ofthe Butlnnsand ProfmionsCode,and my
license is in full fora and effect. PANELS
Llanac Claes L[cNQ
Date - Contractor
ARCHITECT`S DECLARATION 201-1000 AMPS
q�q�vv�Oz Iu ticrs y�wehaBl�pubhcrmmds. - OVER 1000 AMPS SQ. .FLOOR AREA . S/SQ.Fr.
k Used Profen naY' SIGNS ELECTRICAL g L E D I
<«6 OWNER-BUILDER DECLARATION
TEMP.MCIRCUI POE I
ZH .7a 1herebyafRren that l am exempt fromthe Contractor's License law for the
followingmason.(Section 7W1.5,Business and Professions Code:Anycity it
O TEMP. ORIOLE INST.
�,� county which rcqulrcea permit
e,mtutequires alter,theaprovam for,ish,ormit to /�/�
"1m anystmcturc prior to Its issuance, requires appBraN(or each permitto POWER DEVICES
qC a file a signed statement that he,b Licensed pursuant to the proviahms of the
W 34t' Contmetor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC �O VALUATION
�0� sion3 ofthe Business and PMeselonsCode)orthat he a exempt therefromand ll�
6q12the bade for the alleged exemption. Any violation of Section 7011.5 by any OUTL EISSWITCHESFIXTURES yl/I ti]D
applicant fora perMtsubjecis theapplicant to a civil penalty of na..than a (/✓ W
five hundred dollars he pr. NEW RESIDENTIAL ELECTR SQ.FT, STORIES - ]YPECONSTRWHON
�n ❑Lae owner of the property,or he employees with wages r aerie sole
compec.70 ,sousdothework,andions Code;The C Intended oroffered for
C O sae(Sec.apply
to an owner
df property
Code;The Contractors License law .
$.
does net apply loan owner ofthroug his obuilds ne mporimprwotedthatand
F.$^ whodceasuch work himself orthrvughh[eawnemploye.s,provided that such OCC.GAOUI' RFS.[!NITS '
improvements are not Intended mattered for sale.](hcweveq thebuild[ng or TOTAL;
improvement usold within oneyearofcomplellon,theowner-WBderwlll have I�
tl)9 ,xim of proving that he did not build or improve for purpose ofvae.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
U L as owner of the pmperty,am exclusively contracting with licensed PERMIT ISSUANCE ,l�
contractors to construct the project(Sec 7014 Business and Pron fessioCode: A.
The Contractor's License Law does not apply to an owner M property who PETER-DRAIN kVENT-WATER(EA)
Wilds or improves themem,and who contracts for such pkojeea with a
myVIctor(e)hemsed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI am exempt under Sec B 4 P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT x
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP S040OLTAX Y_ N_
❑1 hereby affirm that I have o certificate of acamfi to spy thereof(S • RECEIPT N
certificate of WorkersCompewtlonlmuranceora artlfled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FCE Y N
3800,Lab C.)
Poilga - RECECAS EA.SYSTEM-0VER 4(EA) DINC;DI M
C°^' nY BUILDING DIVISION FEES
Certified copy l9 herebyfamished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
r-1 Certified copy U filed with the city Impaction division. L
CERTIFICATE OF ID(EMPTION FROM WORKERS' GREASE TRAP PAIF _ ��
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Reeel tN
RAisactlon need nor be completed lithe permit V for orae hundred dollars
(5100.tifyth WATER HEATER W/VENT/RLEcTR ENERGYFEE Y N
Icertlfythat in the performance.(the work(orwhlch this permlHsiseued, �j O
I shall not employ any person in any manner so ae to become subjeet to the WATER SYSTEM/TREATING Q-I f 9 t 6�3 $ (�0 `
Worker)Compensation laws.(California.Data PAID l L
Applicant
Z Z NOTICETO APPLICANT-.If,after nuking this CertBlcale of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recei tN
O should become subject to the Workers'Compensation Provision ofthe Labor TOT
N Code,you at forthwith comply with such provlsiom or this Nrrmtshall be - N
`> deemed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
Iherebyaffirrethatthem is a commactlon leadiagagency furter perform TOTAL` ELECTRIC FEE
an
e of the work for which this permit b Issued IS 3097,Civ.C.)
V O Landers Name PLUMBING FEE
LL F Lend.e.Addre a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0
OW Icedifythatl have madth[exppliatiooand statethattheabove Information ,syr
1 iscorned,lagmetoc.mplywlth.Hdtyandcounty.rd[nanre...d data laws PERMIT ISSUANCE (,si PEE$PAID:
relating to building construction,and hereby authorize representatives.(thin
H Z city to enter upon the abovomentioned property for Inspection purposes. ALTERORADDTOMECH. -Date
Recei
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against llabilites,peigments,cons and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,"CFM) $UBTOT
gar teaid City equence of the gram Ing of this permit. '
/(��/r/W `��` ,( pct/ AIR HANDLING UNIT(OV77210,000CFM) CONSTRUCTION TAX
ai5gnamre of AppRant/Contractor l Date EXHAUST HODD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppliant orfuta m building occupant store or Its adle haaaMous HEATING UNIT(TO 100,000 BID) Dale ReCei ter
material as defined by the Cupertino Municipal Cade,Chapter 9,12,and the
I'Icalth and SafeCoda Section 25532(a)? HEATING UNIT(OVER 100,OW BTU) TOT
Safety
RI-1 Yea N No
illtheappliant orfuture building occupant use equipment or devices VEND LATION FAN(SINGLE RESID) ISSUANCE D T'
which emit hazardous air contaminants as defined by the Bay Area Air
lily Management District? BOILER-COMP OHP OR 100,OW BTU)
Yee n❑No,
have mad the hazallous ma terialsrequlrements under Chapter 6.95 of BORER-COMP(OVER IDg000 BTU)
the California Health&Soley,Code,Sectlom 25505,25533and 25534, I 4.
�� understand that ifthe Wlldingdces not mrrcntly have atenanl,tha/it is my NEW RESIDENTIAL MECH. SQFT.
respomiblllty,to notify the omp.ct of the requirements which at be mer - NI';r, p
prior to Issuance of a Certificate of Occupancy.
Ownerorauthmmd agent Date ISSUE
T '
TOTAL: t V
OFFICE COPY