22510 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification '. PERMIT NO,
BuOdmg Add.x 03c o J �� 22510
one: A
n1'�lMCL1/} q •�NYW LLVISDFj CITY OF CUPERTINO-BUILDINGDIVISION
Cant.dar.Name: u..N.: - APPLICATION I PERMIT'
BIIILDINGELECTRICALPLUMBING.MELHAMCAL CATEGORY CO (y.
Architect/Engineer. Lk.No: 49
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 0300 CrO {'on ' (� g�}'1)'I., PEMITISS'UANCE d0
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapterg(commene. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Incense isinfon force and effect.
Buslnesand ProfeWoeCAde,and / / /
Brener binfulfomendetfect. rANE-S -WI I/// /1
Llcanse Ctas tit# ,S keLLL6
Date Contractor LIP TO 2DO AMPS
ARCHPIECI`S DECLARATION 2(11-1000 AMPS
q�q�uu rc Z I understand my plans shall be used as public recorders OVER 1000 AMPS 5Q'FI.FLOOR AREA
fie Licensed Professional MCNSELECTRICAL 5'` 1p I y] ( aaa[���jjj .v�
< OWNER-BUILDER DECLARATION SPFLIALCItCUIT/MLSC Q Itll / {� -`$Lu/
1hercbyaflrmthat l am exempt from the Contractor's License Law for the 6 L� J`ITJ 29 l `
following...(Section 7MIS,Business and Profession.Code:Any cRy or
OR-e TEMP.METER OR POLE INST.
�� countywhlchmquimapert trommima,aller,impmve,demlbh,orrepalr
anystm=mpdortoib Wuamc aborequimtheapp11caniforsurhperMtto POWER DEVICES
Rk a signed statement that he b Ikensd pursuant m the proyyysssyyysss!!l!!!000000s of the
3w� Contractors License Law(Chapter9(mmmendngwlth P' E
SOS sion3 ofthe Busines and PrefesionsCode)orthat he b excen therr VALUATION
< the basis for the alleged exemption. Any violation of Section 7031 by y O FIPj ,�,�1
p appliontforapermlleubie theapplcanttoadvllpemltyofeat Q W
$� f ehundred delta.( 5M. �y(a�,� E SQ.Ff. SIORIPS TYPECONSTRUCTION
�n �I,as owner of the property,or my employee with wag u.111lSso
mmpen.ation,wgldotheworkandthe.tmu mu nmintend orofferedfor
Q1-(See.70K Businessand Profeslm.Code:The Contract. .Lire
$ does not apply to an owner of property who builds or Improv thc.o a
who doessuchworkhimseiforthrough hisownemplayses,p halsuch #*t OCC.GR0U? RES UNITS
Improvements are not intended oroHered formic.If,however,lhebuilding or TOTAL: •"4v
Improvement bold withinor.yearofcompldiomtheowner-bulderwlll have
[F��arden of proving that M did notbuld or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD TONE APN
Ltr 4 cue owner of the Property,am.70K ivelyBuss contracess and ingPro with Is ensedCode PERMIT ISSUANCE
conThe Contractor's
act mnstmms,ct Law jet(Sec.apply
to anowne of protons Code
The Coor Impr's Lkeve law dues nos apply to f owner of property who ALM-DRAIN k VENT-WATER(E) -
Wild.or Improve iheeon,root who mnt.cts for such p(.jerb with. FEE SUMMARY
coBj(ador(s)lice. pursuant rothe Contradora License Law. BACK pIAW PROTECT.DEVICE LJ I car pt a B k P C for this rcaon
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Owner Data RECEIPT M
WO IN IAN COMPENSATION DECLAR 10 �1 MURES.PER TRAP wIl SCHOOL TAX Y N
❑I hereby affirm that 1 have a certNote of.cent to copy
the.(ore ` W/ RECEIPT N
3800,IL bCfWorkers'Compensatlonlnsuranre ora rertlkd mpythereo((Sec. GAS EA.SYSTEM4 INCA OUTLETS R.
VD PARKFEE Y N_
Policy# - RECEITT N
GAS F.A.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEES
ECertifted copy U hereby furnished. GREABE/WDUSTRL WASTE WTEtCF]PTOR PLANCHECiC FEE
❑Certified copy b filed with the city Inspection division. �
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID``_"fI
COMPENSATION INSURANCE SEWER hundred EA 2DOFI Date Recei (# '
(TMsse tion need not be completed if the permit is forma
hundred dollars
($10(Emles.) WATERIffATFR W/VENT/ELECIR ENERGYFEE Y_ N_
I oertifythat In the performance of thew.rk forwhich this permit Is Issued,
1 shall not employ any person In any manner so e to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ3T. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'C.mperuatlon provisions of the Labor TOTAL:
N Codc,you must forthwith comply with such provisions or this permit shall be BUILDING FEE 30 s
deemed revoked.
(L mCONSTRUCTION LENDING AGENCY SEISMIC FEE S
til ]hereby orkfo wbm
there anst.tion lending agency perform. ELECTRIC FEE
Z S�
7 O anreof the work for which this pertNtbb.ued(Sec.3097,C1v.C.) TOTAL: p
3
U _. Lender.Name PLUMBING FEE •0
U. F enders Adam. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE _0
U omect. thatlagree to
appfth all city andc untyordina aboveinfordgat laws
O W bmingto ugreeto complywith all countyordinancestati gate laws PERMITISSUANCE' BUD FEES PAID:
} a relatoenterupon t mruwdloMaodpropauthorizepectionpurpos offhb
fA cityWenteree to theabove-mentioned
as propertyfor inspe Cit purposes. ALTER OR ADD TO MECH.
Z (We)agree to rave,indemnity an d keep hamdes the City of CupertinoDate Receipt#
U - - - ----
against lbbilide.,jadgmenb,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
galId ty In cors encs of the granting of this permit
j 1.LAT2� AIR iANDWNGUMT(OVER IO,000CFM) CONSTRUCTION TAX
signs Imm of ATram/c.m.d.r Date EYHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID: .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(10 IDO,"BTU) Date Revel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -2
Health and Safety Code Section 25532(a)F HEATING UNIT(OVER 100,000 BTU) TOTAL: Z .?D
❑ Yes M No
Will the applicant or future betiding occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whicQuality Management Distrid7aMnanlecue defined by the Bay Arca Air BOE,ER-COMP DHP OR 100,D00 BTO) PAIL)'•. Yea ❑No r!'1IY/
4havemadthe havrdouamaterials requlretrenbunder Chapter 6.95of BOILER.NMP(OVE(100,0011BN) „ �e7
the California Health A Sa fety,Code,Sect lora 25505,25533 and 25534.I �1 V 171
understand that if the building dace not currently have.tenant,that it is my NEW RESIDENTIAL MECdH. SQXT. ��.yY
responsibility to nosily the occupant of the requirements which must be met _ asNa
prior to Issuance of aCertificateof Occupancy. f C alt'•
Owner or authslud agent Data ISSUEDBY:
TOTAL: -OD
OFFICE COPY