22577 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: /�/�I�
01 L0 5o, m 0dkc�sL14 t,3 LV Q G G^/t
nen ams: one:
C LL CITY OF CUPERTINOBUILDING DIVISION
c ntr ctnre ams: Lic.No: APPLICATION /PERMIT
S6 / BUILDING-ELECnUCALPLUMBING-MECHANICAL CATEGORY CONTRCy.'p/'a, L
Architect/Engineer.~ Lie.N. (t,1 q1
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrmc PERWTISSUANCE 2� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
(her by Sectioi 7000).lamlkm3ofthe .sir alnneoRTapter9(rommm APP[lANCESRE5IDENTGL JOB DFSCRB'HON
11...hI.fon 7000)old effeon3oftheBuslmssand ProlusionsCod4mdmy
license Is Ins toren andeff[cl j.S p, c'f PANELS r�C/L.IJ
License Clam LION n
O Q i
Date ComcactorUP TO 2DO AMPS
_.r 7011000 AMPS
ARCHITECTS D CLARATION
N20 I undertanllmy Plans shall be used Public record.. OVER 1000 AMPS SQ.Ff.FLOOR AREA $M.FT.
I�C 11))L.c SIGNS ELECTRICAL
(/ Licensed Pro7essloml
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MSC
Z s,�7a (hereby affirenthat l am exempt from the Contradoes License Law for the
following recon.(Section 70715,Business and Pm(esdons Code:Any dryer
O TEMP.METER OR POLE INS(.
r countywhich requlrnapermltrommtvtt,iller,Mprove,demoWh,arrepalr p /�
gg .c anystvcture priorto its isducce,aho requlrestheapphant(orsuch permit to ]OWER DEV( I�'I .' 1 �l
file a signed statement that he h Licensed pursuant to the provisions of the - ,.
3µ(� Contractor's License Law(Chapter9(commencing with Section 7000)o(Dlvl- SWIMhq NO POOL ELECTRIC VALllATfON
1 si.n3.fthe8U.Inessand Profemlom Code)orthehoiscumptthemfmmand
Q.•�31 the basis(or the alleged exemption. Any violation of Section 70715 by any t f �I I OO q
applicant fora permit subjects the applicant to a civil penalty of not camethan 0[JILE7SSW1 FIESEXTURPS V
flue I,Iso owndoler
of ars
epee NEW R 'DF-NTIALTAW(R SYRTIS TYPECONMUCTION
comp�n ❑e saowmrli theproperty,ormy.mutes isnwlihwages r offered for
theirsole
5 p does
enet apply to an es..nd owner
property
hob:The Cimproves License Law
1{�$ docs not apply torn owner ofthroug his own
nem orimprovnlhercoryand OCC.GRCUP RIS.UNITS
who
nIumn, such
nt,amwork himself ndedorwgh hhowne.If,hoever,thebuil that ing or I O
Improvementsarenet intended earofredforsile.ILhoweverthebuillI have TOTAL:
Improvement iseold withinoneyearafcmnpldbn,theowner-bu0derw111 have
tl,,kurden o(pmving that he did not build orimprove forpurposeo(sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
..i.e.to construct the pmjed(Sec.704k Business and Professions Code: LXr
The Contractor's License law does net apply to an owner of property who
build. or Improves thereon, and who contract. for such ptojeds with • ALTER-DRAIN&VENT-WATER(EA)
Cff,c`;Ve Rcensedpurwne to the ContndFEE SUMMARY
o/s License Law.
I�I am xemq under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
1 DRAINS FLOG ROOF, SANITARY Y N
Owner Date — R RFA��' RECEIPT M
WORKMAN COMPENSATION DECLAR TION FIX.fURES SCHOOLTAX Y_ N_
hereby affirm that I have a nertlRcate,of consent to sell-Insure,ora �as�s REC NN
certlfiale o(Workers'Comperuatlon Insurance ora certRled ropytheino'(Sec. CAS EA.SYSTEM-1 INC.(OUTLETS 2,IW PARK F� Y N
Policy ab C.) RECEIPT If
Polleyp GAS EA.SYS'FEMr OVERN(EA)
Cam any BUILDING DIVISION FGBS '
Certified copy b herebyfamished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FFF
I CE copy b filed with the city Inspection division. IG
CGRTIFlGTE OF IXETNPTION FROM WORKERS' GREASE TRAP - PAI �y
COMPENSATION
INSURANCE EA 200FE - Date Re III ,'�1M
(Thissection need net be completed(the permit 0 for one hundred dollars
(sip unife,a) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
I unify thatin othe person Iaofthaworknner fa,as
became
permlHsbared,
I shall not employ any person In any manner at u to become object to the WA.I.Et SYSTEM/TREATING
Worken'Compematlon Gwsof Callfomh.Date PAID _
O Z Applicant NEW RESIDENTIAL LMB. SOFT. Dale i IN
Z O• NOTICE TO APPLICANT:R,.fter nu king this Cerifirdeo(Exemptlon,you
Fshould become subject to the Worker'Compensation provisions of the Labor T TAL:
N Code,you must forthwith comply with such provisions or this permit shall be U cQ7
W deemed revoked.
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Ihereby alflnnthat there is a construction lend Ing agency for the perfono- TOTAL: (� ELECTRIC FEE t
Ince of the work(or which this permit 6Issued(Sec.3097,Civ.C.)
O O Lender's Name PLUMBING FEE I t
F- Lender'.Address QIY. MECHANICAL PERMIT FEE
O W I certltythatl havereadtNs appllationand statethattheabovetefnmvtion MECHANICAL FEE
CL bcorrect.l agreeto comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
relating to building ronstvctioq and hereby authorize rep rnerstativea of thio
H W city to enter upon the above-mentioned property far inspection purposes. ALTER OR ADDTO MECH. Date R i RN
_ (We)agree to ave,indemnify an d keep harmiess the City of Cupertino P
against Babitties,jsdgmem>,roetsande.penses which may In eny..y.e.a AIR HANDLING UNIT(TO 10,000 CFM) SUBT TAL:
age Inst said City in mnsequen (the grant og of this permit.
O` Datp _(p AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Sign �moMppRant ntnctrn eq� " � DwAUS'r HOOD(W/DUCT) CONSTRUCTION TAI PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(utum building occupant store or handle hazardous I HEATING UNIT(M l 0Q,000 BTU) Date Rep ' IN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Q
Hmh h and Safety Code Section25532(a)2 HEATING UNIT ICY ER IM1000 BTU) O L
❑Yrs M No
Will the applicant or future building occv pant use equipment or d evices VENTILATION FAN(SINGLE REBID) Cil" S �DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management Diorid7 BOILER-COMPOHPOR100,003ILTU) f
4Yea ❑No `hll�(n�� /
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �'l K ONLr.ae_
the California Health&Safety Code,Sections 25505,75533 and 25536. 1 �'�9�I�
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
rmpomibility to notify the occupant of the mquiremenb which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorised agent Date ISSUED BY:
TOTAL;
OFFICE COPY