22555APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Bu Ing naareaa, 44,ee ora
PERMIT NO.
22555
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CITY OF CUPERTINO�BUILDINGDIVISION
APPLICATION / PERMIT
BUILDINGELECTWCAI..PLUMBINGMECHANICAL
A
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Contractor's Name: L�I$.Nm
3ZY372
EG
CATEGORY CONTROL N
BUILDING PERMIT INFO
.Nltact/Fsgincar Lic. Na
QTv ELECTRIC PERMIT FEE
n
A?f c (,
PERMITISSUANCE
❑ ❑ 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am Licensed under provWons of Chapter9(mmmenc
ion7000)of Dlvislon3ofthe Buslnessand Profs .nsCode, and
license is Inls in fuL dfect. 3 3 7 Z
LlmnseC nLIc.Y
Date Contvtlo yyyy� aa��S
ARCHITECADECLARATION-rl
lunderetand-yplxrushallbe.x .pubhcreconla
Licensed Prolessiorul
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
following reamn.(Section 7MIS, Business and Professions Code: Any city or
caantywhichrequiresapermittommtmct,altertr pmve,demolhh,ormpair
any structure prior to Its issuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
non3 ofthe Business and Pmfessimu Code).,that he is exempt therefrom and
the bels for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars ($500).
1, as owner of the property, or my employe" with wages as their sole
E] 1,
compensation, will do the work, and the alnclu re is not intended or offered for
sale (Sec. 7044, Business and Profeasimu Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon.and
who does such work hlmmiforthrough his own employees, provided that such
Improvements arc not Intended oroffemd forsale. If, however, thebeilding or
Improvement bsold withinoneyearofcompletion,the owner-bullderwlil have
t iajlurden of proving that he did not build or Improve for purpose ofsale.).
Lf I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sm 7614, Business and Professions Code:
Tlu Contractor's License Law does not apply to an owner of property who
builds or Improves therein, and who contracts for such plujects with a
maorta licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B & P C for this reason
APPLIANCESRESIDENTfAL
JOB DESCRIPTION
j� //+��
j' �� ri lCt� �e
D S
PANELS
7111-IODOAMPS
OVERIODOAMPS
SQ. IT FLOOR AREA
2-7
$/SQ. FT.
SIGNSELECTRICAL
SPFGIAL CEiCITIT/MLSCA
Pass
TEMP ME'PIR QRI'OLE]
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
)
(
OLMILTSSWITCHES.FIXTURI S
NRWRFSiDENTIALELECTR
STORIES TYPE CONSTRUCTION
TOTAL:
QTy, PLUMBING PERMIT FEE
OCC.GROUP RES. UNITS
FTOOD ZONE APN
PERMIT ISSUANCE
ALTER -DRAIN VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
n1ITSIDE FEES
DRAINS FLOOR ROOF, ARRA, COND.
FiXNRFS PER TRAP
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
that I have a rti te of consent to self-Inmre, or
,[:]I hereby affirm mfka
ceniRale of Worken'Compansati.n lruu rano, o, A rifted ropy thereof(Seco
38M 1.bC. ��nn � n/�
P.Ery#b ) T7 /y"
SCHOOL TAX Y N
RECk9'l. N
GAS FA. WC.I OUTLCT'S
PARK FEE Y N
RECEB'T N
Ono, an y
GAS G.SYSTF7d-OVFRI(EA)
BUILDING DIVISION FEES
CenlOcd ropybhercby lurnlahed.
f .Hified copy is filed with the city hupection division.
IWC'
CERTIFICATE OF INEMITION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit h for oro hundred dollars
(5100)mlyth
Icenot thatlnan person In nce
I shall not employ any person In any manner at ae to become subject to the
tmnnerhe work forwhlbecomech this ermltbbothe
Workcrs'Compensatlon laws of Calllnrnh. Date
AppliNOTICE aftermakingthisadionkro o(ExempteLyou
should NOTICEco esubjCt to
Code,bacon, subjecttothe Workers' such pruatlon or this permit forthwith shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afflrmthat them As acomlmctlon lendingagency forthe perform-
of the work for which this permit b bored (Sec. 3097, Civ. CJ
Iender4 Name
Lenders Addmss
I cenllythat l have read thbapplicationand alatethatthe above information
is correct. l agree to complywlth all city and county ordinances and nate laws
relating to building mmtmctl.n, and hereby authona representatives of this
aty to enter upon the above-mentioned property for bupectlon purpose,
(We) agree to save, Indemnify an d keep harmless the City of Cu perUna
against liabilities, ydgmenb, Corte and expenses which may in any way accaue
against calci City In the grY,{Ing oft=his permit
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GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Remi thI
GCSE TRAP
SEWER -SANITARY -STORM EA. XIORf.
WATER HEATER W/VENT/ELFCTR
ENERGYFEE Y N
PAID
Date Recei Hf
WATER SYSTEM/TREATWC
NEW RESIDENTIAL PLMB. SOFT.
LNG 'E
Od
TOTAL:
SEISMIC FEE
_
ELEcralc FEE
QTY. MECHANICAL PERMIT B
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date Bartel I#
P
AIR HANDLING UNIT (T010,ODO CFM)
SUBTOTAL:
s
FPR HANDLING UMP(OVFR IO,003 CFM)
CONSTRUCTION TAX
-CONSTRUCTION
SI m fAppllont/C.rmeu �� Date
HAlARDOUS MATERIALSDISCI.OS RE
Will the applicant or future building occupant atom or handle hazardous
material as deflned by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Codc Section25532(a)?
❑ Yee M No
W111lheappllunt or future building rampant use equipment .,devices
which emit hmaml..s air cont.mmenb as defined by the Bay Area Air
Quality Management Distn07
YeeNa
haveresdthebaza o...tcrialsrequ(m, entsunderChapter6.95of
he California If aith&Safety Cole, Se Inns 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
res poruibllyitpytonotify the occupy nt of the req,hements which must be
pnort.lss nceo a enRleate cu pa cy�
/6t6PFj,�lr/// II/J
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EXHAUST HOOD
TAX PAID:
HEATING UNIT (TO 1110,000 BTU)
Date R2Ce1 IM
HEATING UNIT (OVER 100,000 BTI!)
TOTAL:
VENTILATION PAN (SINGLE RESIW
ISSUANCE DATE
Ny
ISSUEDBY:
BOILER-COMPOHPOR 100,0(D BTU)
BOILER-COMP(OVER100,0DO BTU)
NEW RESIDENTIAL MEC} I. SQ 1-7
e rr ria agent pate
TOTAL.:
OFFICE COPY