22164 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NO.
Building Address: 22164
2 -1r/ �a 'r
nera ante. - ane. A
w CITY OF CUPERTINO-BUILDING DIVISION
.
C"a"
" aetnra am Lic.N. APPLICATION / PERMIT
N T
BUILDINGELEC7RICA4PLUMBINGMFLHAMCAL CATEGORY CONTROL N6SG
Architeci/ glneer. Lk.No: V
S - ` QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:�GC�@�.j F S I PERMITISSUANCE �2aCS� fes'
LICENSED CONTRACTOR'S DECLARATION X
I herebyaffrmthat lam licensed under pwIslonsof Chapmr9(rommenc APPTIANCFSRESIDENTIAL JOB DESMHON -
ing with Section 7000)of Division 3 ofthe Busincssand Pmfes.UonsCode,and my
It. lain full f d effect. PANELS
Llrenseckaa Lic.R 30 1 �t�/ 25 pts T-- 6Z6e�C�Q
Date$// cHITEmr1 201-1000AMPS
ARCHITECTS DECLARATION OVERIODOAMPS SQ.FT.FLOOR AREA $/c.Q.FT.
qG'+1 z Z I understand my pore d u rem
shall be usepublic rdw 1
00
L+do Licensed `
Professional I SIGNSEI.ECTRICAL (O1OD ' � 43 7':'
Z
Q nt OWNER-BUILDER DECLARATION
G,�Fn SPECIALCIRCN7/MLSC
Z8
y owing rasormthatPam emmpHroossa Contractor's License Law fort he
O Z F following reason.(Section 70115,Business and Professions Code:Any city or TEMP.MEM OR POLE INST.
FSI countywhich requtresa permit toconstmct,alter,improve,demolish,orrepair
11 .a anystmcome prlortolts Issuance,also requires the applicant forsuch permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
�aContractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING IDOL ELECTRICA �N
slon3ofthe Bu.n..ndPMe i.o Code)orthxe
athebempttherefromand
g O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
appBant(ora pemdt aubjn b the applicant to a civil penalty d na nnrcthan
five hundred dollars($500). NEW RESIDENTIALELECTR SQ.FT. NSTRUCTION
F1 1,as owner of the property,or my employees with wages as their sok /
7. compensation,will Bathe work and the.trodurebnot intended or offered for /
p safe(Sec.704k Buslnev and Prufessiom Code:The Contractor.Llaree Law
$ don not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS'
who does such work himself or through his own employees,provided that such
improvements arc not intended or offered for sale.If,however,the building or TOTAIipjI
improvementL soldwithinoneyearofeo plelomtheowner-Wllderwlllhave
the rdenofpmvingthat he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
L j L as owner of the property,am exclusively contracting with licensed
contractors Womstruct the project(Sec.7046,Business and Professn Code: I I'FRMIT ISSUANCE
io "1 OD
The Contractor's Llmose Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) �C�
Wilda or improves thereon,and who contracts for such projects with a FEE SUMMARY
<gIl[�actorts)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L,J I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner ECL RECE4T N
WORKMAN COMPENSATION DECLARATION FDCHJk6S PER TRAP r-) � $CI10pL TA% Y N
�hercby affirm that I have•certificate of consent to self-Insure,or 4 RELENT X
certillateofworkem'Compemationimumnmoramnifiedmpythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38001Lab C)
Policy p RECEBT a
Comer SAT GAS FA.SYSTEM-OVE]44(EA) BUIL DING D I VIS ION FRGS
�Cenified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
f2CertiOed copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SCORN EA 200Ff Date Reoci f#
(This section need not be completed if the permit b for ane hundred dollars
(5100)or1ess0 WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N—
I certify that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any nner so u o me bje<t to the WATER SYSTEM/TREATING PAID
Work er*C.mpensation lasv.of Glif � Di�ahe LT
ZZ Applicant /O 64 NEW RESIDENTIAL"B. SFT. Da[e RCCeI t#
O NOTICE TO MPLICANT:If,niter n th ertlflate of Exemption,you
H W should become subject to the Workers''CompeUoa provisions of the Labor TOTAL:
Cad,you res at forthwith comply with such provisions orthis permit shall be BUILDING FEEr(�
deemed revoked.O CONSTRUCTION LENDING ACTTCY SEISMIC FEE
dI hembyafRrmthat there b a construction lendingagenry forthe perform- ELECTRIC FEEM Z ancoofthework forwhich this permit fs Issued(Sec 3097,Civ.C.) —
C) O Lender.Name Ty, MECHANICAL PERMIT FEE PLUMBING FE•E
OD
LL H lenders Address Q MECHANICAL FEEC�
OW Imrtify thatl have read thosapplicatlonand natethat theabove Information 3�
IL Incorrect.Iagrm to comply with all city and countyordinanm and nate laws PERMIT ISSUANCE 2_ e� FEES PAID:
>- relating tobuilding conswctlon,and hereby authorlu representatives ofthb
I— N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDIOMECH.
z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against lkbllitles,Odgments,coneand expenses which my in any way accrue AIR HANDLING[NIT(TO 10,01)(CFM) SUBTOTAL:
against said City In conentt o,f3he gr antingof thls permit.
AIR HANDLING UNIT(OVER IQODOCFM)
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Sigmtu o!A lent/Contras Z—n Dat FXHAUSTHOOD(W/DICT)
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplla rat orfumm building occupant store or handle hazardous HEATING UNIT CFO IOQODO BTU) Date RCCci t#
material as defined by the Cupertino Municipal Cod,Chapter 9.12 and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 'I.Zo
❑Yes In No
Will the applicant orfuturc building occupant use equipment or devices V ENIILATION FAN(SINGLE RFSID) ISSUANCE DATE
which coral hazardous.1,contamlm rats as defined by the Bay Area Air 1.7 ati G'
Quality Management Distrl 7 BOILER{OMP OTN OR 108000 BTM
4Yes o 1 a� 1nQ
h aye read the haea oils ma(erlals requirements under Chapter 6.95 of BOILER-COMP(OVE2100,000BN) JUN
the California Health&Safety Cade,Sections 25505,25533 and 25534.I v
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
respomibilitywornifytheo pant oftherequlrements which must be met (51}y asf�Q$}�Ifq
prior to issuance of a Certl a ofQecvpanry.
Ow r zed agent / r.y,TOTAL: ISSUED BY:
a
OFFICE COPY