22409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prnectleentifestion PERMITNO,
Bu Oding Address: 22409
a av� one:
Q-�c�--✓ oli /n" CITY OF CUPERTINO-BUILDING DIVISION ��_rJ
c a nr ,me: LIa.Nn: APPLICATION / PERMIT `�
BUILDING-ELECTRICAL—PLUMBING—MSCII IANTCAL CATEGORY CONTROL p
A cis tact/Engin r.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre,.
❑LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE ❑ El-
Ihereby
Action 0thatlam Bcensedunder irassaprovisions of Chapter9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
lican h5le 7000)of d died
oltheBminneand ProleselonsCode,antl my
Ilcense Isle f dLic A: a� PANELS �•_ _ �7_ -arm_ �Saar
LImnLlc.p�p0 AMPS
�ln(,T l*—f`II FV�a` '\\�Ja1RLv`7^�SY-�
Date Contractor LM TO 2DOAM
ARCHITECTS DECLAR N
µOS
9
0 O I understand my plam.hall be used As public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
U6 Licensed Professional SIGNS ELECTRICAL
«<<'kq OWNER-BUILDER DECLARATION xYV
zl-"YYaAA Iia Ihereby afflrrnthat I am exempt from the Contractor's License Ow for the SPECIAL CIl2CUIT/M1SC
following reason.(Section 7Ri15,Business and Profession.Code:Any ctty or n S/s s O
Ocounty
TEMP.METER OR POLE INST. 0 1 !V!\`II
�� anystmhmph orltolt. r...,.Immqui .themplientfmoWh, er ttr
any atrocture tatemelte that
he poisoned pursuant
to the
rovisl m of t e POWER DEVICES
O Ric a signed statement that het licensed pursuant it the pro 70ft of theV KI
y6(± Con3 ofthelusine and Law Fodead aCodO ommng lht els xSection
mpttherefof andiel. SWI MING POOL ELECTRIC
t, .:1771 the basis fo Bushesend Pmfenlon.Modulation f exempt therefrom and VA
the boob for the alleged exemption. My violation of Section 70115 by any OUTLETSSWITCHMFO('TURFS
Applicant for a permit setb)c.the applicant to a civil penalty of not..than
flue hundred dollars hepr. NEW RESIDENTIAL ELECTR SQFf. NSTRUCTION
�n ❑inei owner l theproperly,ul he employees with wages as their sole
romper.70 ,Business workfceshe stmde:Tboot Intended oroffered(or
.1.(Sec.7044,Business and Professloru Code:The Contractor'.Wamelaw
cS does not apply to an owner of property who be lids or Improve.thereon,and
$^ who does.work Meneelforthreugh his own employees,provided that each OCC.GROUP S
improvements are not Intended stuttered forests.ILhowever,thebuildingor TOTAL: OA E
Improvementissold within oneyearofcompletlon,lheowner-bullderwlll have
HiLJZurdeno(provingthm hedldnotbulldorlmproveforpurpoeeo(sale.). QTY, PLUMBING PERMIT FEE plppp ZONE ApN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the perfect(Sec.7014 Business and Professiom Code:
The Contractors License Law don not apply to an owner of property who ALiIILDRAW k VENT-WATER[EPA)
W lids or Improves thereon,and who contracts for such ppoce,with a FEE SUMMARY
sgp((actor(s)licensed pursuant to the Contractor's Lt.-..Law. BACK FLOW PROTECT.DEVICE
I em exempt under Sec. B k P C for this reason
.11T1113E FEES
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N
Owner Date RECFRPI'B
WORK MAN COMPENSATION DECLARATION pT%TURpg PER TRAP SCIi00L TA% Y N
❑e hereby affirm that I have• l rtcone of consent to pythn ore,ora RECEIPT I
certlRate ofWorkers'Compewtlan lruuranamacenifled copy thereof(Esc. GAS F.A.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
3000,Tab CJ. r �� _ RFLEPTN
PoliryM tAll GAS E.A.SYSTEM-OVER4(EA)
Core
om nIBUILDING DIVISIONFPaiS
�Cendled copy b hsrcby fumle�. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
enlled copy b filed with the airy Irupemlon division.
CERTIFICATE OF E%EMPTION FROM WOR K ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.20OFT. Date Rett'1 l#
(T or lm.)n need nM be completed tithe permit b(Drone hundreddollars
(SI°B) tiles') WATER HEATER W/VLNT/ELECTR ENERGYFEE Y N
I cent that to employ
an person
nce In an thewakAn for
As to b co pertnBbblued, —
1 shall not employ an/perws In any manner at x t-become subject to the WATER SYSTIEM/TREATING
Workers'Compernation Paws o(GBfomh.Date PAID
0 Z Applicant NEW RESIDENTIAL I'LMB. SQ.FT. Date Remi t#
Z Q NOTICE TO APPLICANT:ILaaer making this Certificate of Exemption,you
should bemme.ubpct to the Worker:compensation provision of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthis permit shall be BU
LU 7 deemed revoked.
d c CONSTRUCTION LENDING AGENCY SEISMIC FE
I herebyaffir n that there is a construction lending agency forthe perforrry ELECTRIC FEE
Z anre ofthe work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
U O T<nder:N.me PLUMBING FEE
LL F Iender.Addrcss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irchtlythatl have read thbappllofion and statethmthe above Information –�
IL Iscorrect.l agree to comply with all cityand county ordinances and nate laws PERMIT ISSUANCE FEE$PAID:
Y relatleg to building construction,and hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
L)
against liabilities, costs end expenseswhich may m..ywayacerue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
al t Id Clty In consequence f the granting of this peer t. p
�0 AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
S N of Appllant/Contractor I Da IXHAUSTHOOD(W/DLICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappliant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0001ITIA Date Recei t#
mmerial as defined by the Cupertino Municipal Cade,Chapter 9.11,and the
Ilealth and Safety Cade Section 2SS32(a)I HEATING UNIT(OVER 100,000 BTU) TOTA.:
❑Yea No
Will the appllcantor lure building occupant...equlpmeatordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emlt barardous air contaminsnt.as defined by the Bay Arca Air ��
Ih
•
Quality Management D❑bl BOILER-COMP DIN DR 100,000 BTU)
Yes N NNo o
averch.Rus testuamatemab requirements under And 2SS 1. I of - BOILER-COMP(OV172101),000 BTU) .' ,a.
lbcerstfnd tHealth he bSafety Code,Seatbnsntly have
a tend,that I r '{?r u �ggy
understand Natr lily the ing occas on ofnot herequire encs which)that It met NEW RESIDENTIAL MEt7T. SQ.F7
responsibility to natty the occupant of the requirements which moat be mm �/9�as�
prior to Issuance of a Certificate of Occupancy. 4 .Sal
Owner or authoomd agent Date ISSUED BY:� /�
TOTAL
OFFICE COPY