22838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address:
/y� /(,}�, �s " 22838
O,jru6-0 re � i Y� ! l A A A
ame: Ih
e CITY OF CUPERTINO-BUILDING DIVISION
Cont or'aN Lie.N.: APPLICATION / PERMIT
Architect/Engineer. Gc N. BUILDING-ELECTRICAL-nU BING-MECHAMCAL CATEGORY CO OL N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmthat)am Bon3oftheunder ne isionsoff h.i.,r9(commeno APPLIANCES-RESIDENTIALingwitJOB DESCRBTION e
It...I.
fon 7000)ofdAffeon3ofthe BusinexandProlessionaCode,and my �0 ,^yl,-r
Ilrenxblass force and c.0 PANELS VPFL�a W r'✓� fT
DateLiceba Com R.EPR1'¢.. Tom„
Date Contractor
ARCHITECTS DECLARATION 1
M:,
O I understand my plans hall be used m public records. �[�;r PS
SQ.FT.FLOOR AREA E/SQ.FI.
11bLicensed!Professional GNSELECTR C
I6^�
OWNER-8
UILDER DECLARATION tis/r/-11IV SPECLALCIRCU[ TSC
IherebyaffirmtMtlamexempt fromthe Contractors Llcenx Law he
oo following reason.(Section 7(31.5,Business and Professions Code:Any city or
O 2 f TEMP.MEITR OR POLE INST.
F� anytructum requbna busanmcosomqui Iter, applicator
for
to
anyswmrre pdorto its kwan<e,aiso requiresthe appeant(or such perMOn POWER DEVICES
O K F file a signed statement that he Is licensed pursuant to the Provisions of the
a 4 Contractors License law(Chapter 9(mm rkneing with Section 7000)of Divi- SWIMMING I00L ELECTRIC O sion3 of the Business and PeufesedomCode or that heisexempttherefromand VALUATION
y.'g the basis for the alleged exemption. Any violation of Section 7MI5 by any
Applicant for tsub' the applicant to a civil nal of not sure than �D OUTLETSSWITCFWSFTXTURES
ve dollars
)Ms PP penalty W�1
Bve hundred dollare he 0tH. NEW RESIDENTIAL ELECTR
7<n c❑I,asowneroftheproperty,orsem empioyeeswithwage or
SQ.FT. S70RIfS TYPE CONSTRUCTION
ompemation,wllldothe work and thestrvdure b not Intended or offered for
a R sale(Sec. pply Bu sinessand Profession Code:The orimpctols vent hereon Gw
p�� who ddoes oes
apply loan owner ofproughhisperty onempoympmovided that such
OCC.GROUP RFS.UNLTS
a whodcessuchworkhimxllorthraugh hieownemployees,provided thatsuch
Improvements are not Intended or offered for sale.If,however,the build Ing or TOT
MS
Improvement bsokl wlthisoneyearofcompletion,the owner-builderwlll have
n of proving that be did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FTppDZONE APN
owner of the Property,am exclusively contracting with licensed PERMITISSUANCE
ay.t
tractors to construct the project(Sec.7014,Business and Professions Code: CA/
The Contractors License Law does not apply to an owner of property who �.�DRAW&VENT.WATER(EA)
Wilds or Imp..thereon,and who contract for such p(oiedn with a
c
nctor(s)licensed pursuant to the Contraders LicenseLaw, BACK FLOW PROTECT.DEVICE FEE SUMMARY
am exemp under Sec B&P C for this reason
DRAINS FLOOR ROOF,A SANITARY Y_ N_
. OUTSIDE�LEI
Owner Date ERT N
WORKMAN COMPENSATION DECLARATION FIXTURES LT PER TRA!'
C311 hereby affirm that I have a consentto re
iBrate of consent self-Insu ,ore EN«
.Aiflcate of Workrs m
eCapenullan rnumem ora certified copy thereof(Sec. EN
MOO'Lab C.) GAS EA.SYSTEM-1 INCA OU&M A N
Policy# ECE�p M
Com any GAS EA.SYSTEM-OVER4(EA) UILDRCEFTING VISION FEES
� .Heed copy Is hereby famished.
❑CedlOed copy bflled with the city inspection division. GREASE/1NDUSLRL WANE INTER CE PTO -C FEE;
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP URAPAID
COMPENSATIONINSURANCE Date ReOti t#
(Fhissectlon need not becompleted the FerrettiSURA b(prone hundred dollars SEWER-SANITARYSIORM EA 200171.
(5100)rtifytJ WATER HEATER W/VENT/EI.ECTR ENERGYFEE Y N
I certify that In the performance of tmanner for veto b this permit is leveed.
1 shall not employ any person in any manner so n to become wbjed to the
Workers Compensation Laws of California.Dale WATQt SYSTEM/TREATING PAID
C• Z Applicant
Z O NODCETOAPPLICAM.1f,aRerrt Mngthls Cedlfimteof Exemption,you NEW RESIDENTIAL PLMB. SQj,E. Date Recel t#
should become subject to the Workers'Compensation pmvblonaofthA Labor Lsz` TOTAL:
LU~ f/) Code,you must forthwith comply with such provision orthb perMt.hallbe (�
> deemed revoked. BUILDIN E
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z Ihereby afRrmthatthcre bacontructlon lendingagenry forthe perform TDTAL: ELECTRICFEE
ante of the work for which this permit b Issued(Sec.3097,Civ.C.)
U 0 ender' Name PLUMBING FEE
LL F Lender's Andress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certifythatl have read thbappticalonand statethattheabove Information
d Isco,ne I agree to comply withal)city.ed county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authmL,e representatives of this
(— Z city to enter u Pon the above-merdlomd property fm Inspection purposes. ALTERORADDTOMECH.
V Z (We)agree to save,Ind emntfy an d keep harmless the City of Cu pentre Date Receipt#
against Baba tles,ptdgments,meta and expenses which may In anyway crus AIR HANDLING UNIT 10,000 CFM) SUBTOTAL'
againstsa i inconsequence of the graa-H o this permit I�
2 AIRHANDWNG UNIT(OVER ULLDucFMI CONSTRUCTION TAX
g tvre of Applicant/Co -tor Date IXFIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAPARD USM E IAL$DISCLOSURE
Will the applicacat orfuture building occupant store or handle haeardous HEATING UNIT CFO 100,000 BTU)
material.,defused by the Cupertino Municipal Code,Chapter 9.12 and the Date Retei t#
1 lealth❑ Yee Safety Code Section 25532(a)i HEATING UNIT(OVER 100,00)BTU) TOTA .
Will the epplka...I,or lure ilding dprudi by equipment ordevim VF1J77LA710N FAN(SINGLE RESIDI NCE DATE
which mut kavnlor air old
ascupant use
the Bay Area Air
.
Quality Management Disirid7 BOrLERCOMP QHP OR I00,CM BTU)
4Y" nn No n
havereadthchaaousmaterials requirements underChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 2:534.T a
understand
ytorthe the ing occdoea notof e currently have a tenant,that homy NEW RESIDEMIALMECFi. SQ.F7. �f\
nspoto Issutyto of a Certificate
of rmpa requirementswhicb mustWmel
prior to Issuance of a Certllicate of Ompanry. �7aT
Owner or authorlud agent Date
TOTAL: ISSUED BY:
OFFICE COPY