22737 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address:
2°450 STcv S G Fac �r� 22737
i
one:
"tg CITY OF CUPERTINO-BUILDING DIVISIONntrartn: Name: LIe.N°: APPLICATION / PERMIT
�• BUILDING-ELECTRICAIPLUMBINC-MECIIAMCAL CATEGORY
/' gbuar. V OLJe.tUa/ `f- BUILDING PERMIT INFO
QnELECTRICPERMIT FEE
Address: 1�5lI/��Yn PERMITISSUANCE' 1L1` t
LICENSED CONTRACTOR'S DECLARATION x
I hereby affirm that(am licensed under provisions of Chapter 9(oommene APPLIANCESRIESIDENTIAL JOB DESCRIPTION
ingwlth Satton7000)ot Division 3ofthe Busmak and ProfdssionsCode,and my
Iicenn is In roc anaeffed. ��Gi4) PANELS
-
Lkensc LIc.a 77 �(�i
Date
Contra RorLII!TO 200M,29
ARCHITECTS DECLARATION 701-t000AMI'S
00O !understand my pions shall be used upublic records. OVERIODOAMPS SQ.FT.FLOOR AREA $1 a}1 /SQ.FT.
�
k Licensed Professlorul
6 OWNER-BUILDER DECLARATION T/ a
p„ Ihereby affirm that i am exempt fronethe Contractors License Law fors
p q�p following reason(Se tion 700.5,Business and Pretensions Code:Any city or
Fg coantywhich requires a perrrdt to construct,kter,Improve,demolish,or repair METER OR POLE INST.
Y�Y 7a anystmu mpdorwitslsaance,aWrequlmtheappllantforsuchperMtto p ��•, g
r4 V Ble a signed statement that he is licensed pursuant to the provisions of the -
3w fContractor's License Law(Chapter9(occumocingwithSectionMEETofDivl-n SWIMMING POOL ELECTRIC
f,�Os slon3 o!lM1e Bukinueend ProfenlonsCode)orthet he Vexempttherefromend VALUATION
6 the basin for the alleged exemption. Any violation of Section 7MIS by anyI` VILETSSWITCHESHXTURES 660
applicant fora permit subjects the applicant to a civil penalty ofnt more than ( /a��
p� five hundred dollars($SM. NEW RESIDENTIAL ELECTR k STORIES TYPE CONSTRUCTIONSQ.FT.
❑1,as owner of the property,or my employees with wages as their so
compensatlon,wllldothe work and thestruture is not intended or offend for
Osole(So.70K B.knes,ind Pmfesslou Code:The Contractor's Licata°Law
$ does not apply to an ownerofproperty,who Wilds or improves thereon,and
who doessuch work himself orthrough his own employees,provided that such �( �'e e
Improvereenbare not intended oroffered forsale.15hownmr,(hebulldingor TOTA `v� U
Improvement 9sold Mthinoneyear°fcompitton,theowner-bullderwlll have 30)
t rden ofprovingthat he did not bulla orlmprove for purpose ideals.). QTY, PLUMBING PERMIT' FE• E[-OOppp
{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE TE ` j
contractor.to construct the projet(Sec.7044,Business and Pmfentnns Code:
The Contractors License law does not apply to an owner of property who
Wilda or Improves thereon, and who commis for such p�ojete with s ALTE'DRAIN&VENT-WATER(E.,
cgp�Tec ator(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under SB&P C for this reason
DRAINS FLOOR ROOF,AREA, NU. SANITARY Y N
-� OUTSIDE FEES
Owner Date RECEIPTp
WORK MAN COMPENSATION DECLARATION I.7X'NRES PERTRAP SCHOOLTAX Y N
QI hereby affirm that I have a certiRate of consent to opytnsure,(s . RECEIPT N
3800,Lab ufWorken'Comperwtlonluurance oracertlfled capythereo((5ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3BOq lab CJ
CoIcy R GAS EA.SYSTEM-OVER 4(EA) RECEIPT M
ny BUILDING DI VISION FEES
Ified copy V hereby th the city CREASE/INDUSTR,WASTR INTERCEPTOR PLANCHECK FEE
Certllled copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID_
- otWcomCOMPENSATION
INSURANCE 3,
Use
hlstlon need not be completed ifth.permit b(Drone hundred dollars SEWER-SANITARY-STORM EA.MOVE Date Remipt
($100)orless.) - WATER IIEATIx w/vENr/FI.ECIR ENERGYFEE Y N
I certify that In the performance of the work forwhich this permit Is Wved, —
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workere'Compensation Laws of Califomh.Date PAID
O Z ICM
Applicant NEW RMDO-MAL PLMB._SQ.FT. Date RcDai
Z O NO hOTETCE TO APPLICA :I{after making this Certificate of Exemption,you
should be..subject to the Workeri Compensation provli lons of the Labor TOT
~ 47T Code,you must fort hwith comply with such provisions or this permit shall be
j deemedrevoked. B
CONSTRUCTION LENDING AGENCY SEIS EE
a Iherebya(firm that there is a construction lending agency for the perform EL T
Z anceo(the workfor which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
0 O Landees Name - - PLU GF
U. L nder's Add... QTY. r MECHANICAL PERMIT FEE MECH NI
OW Icertlfythat l haveread this appliationand statethat theabovelnfmorotlon �f}
1 bronet.I agree to complywlthall citysed cuuntyordinancea and tate laws PERMITISSUANCE y FEES
}, relating to building construction,and hereby authorize repeasentativesofthis
Z ' city to enter upon the a bove-mentioned property for inspection purposes. ALTERORADDTOMECH. D CI f#
V _ (We)agree to save,Indemnify an d keep barmier.the City°f Cu pertien P
ago rej liabilities,ydgments,mks and expenses which may In any wayaceme AIR HANDLING UNIT(TO 10,000 CFM)) SUB TAL•
agal Itl City In mnssyuence h among of this permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TA
gra of pp ant ontrator Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX P ID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or tutum building occupant store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Rece t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI!) - TO L•
❑Yen M No
WWlhe appllantorfuturebuildingoavpant usebythe Bay Area
devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which eMahazardousair rict? nb as deOnM by the Bay Area Alr
Quality Management DlaWt7 BOILER -I'OR 100,ON BTU)
qYea g No
have read the hav us matetalaonfeimmonts under Chapter 6,95 of BOILER-COMP(OVEd 100,000 BTU)
the California Health&Safety Coda Sections 75WS,25533 and 75534. 1
onderstaed that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.IT ✓ a�J�
responsibility to entity the occupant of the requlrcments which must be met ®O
prior to Issuance of a Certificate of Ottvpancy. ��ff
Owner or suthorlud agem Date - ISSUED BY �%aY'\–'�–"�'_
TOTAL:
OFFICE COPY