22910 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT-PEN ONLY ,
Building Project Identification PERMIT NO.
Building Address: - - 22910
Lr fiefs done: One:
✓C>^ G,, CITY OF CUPERTINO-BUILDING DIVISION
G°^traders Name o LIaNd APPLICATION / PERMIT
-� Archl ed/EnZZ neer. ...f ' gU[LDINC-ELF-CTRICA4PLUMBING-MECIiAMCAL CATEGORY C ^til�Y-2
LM.No: ` f/
QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO -
Addreu I PERNUTISSUANCE
LICENSED CONTRACTOR'S DECLARATION 1 I-1,•F L�
I hereby affirmthat l am licensed under provisdons of Chapter 9(mmmenc: APPUANCFSRESIDENTAL JOB DFSCRBPTION
Ing with5edlonl(IIOp)°f Dlvlelon3o(lheguelneseand Pmrensl°nsCodgand my - - /i
license lslnfullforceandeffttt. PANELS ,j/.(J5/C /"GIasI /y �G•s
.License Chs, LIeN /
Date Contractor
ARCHITECTS DECLARATIONi X11-1000 AM 7 • a �2c��
NX0 E5 Iundentandenyplaroslugbe used as public rerorda OVER 1000 PS .I ! t T SQ:FT.FLOOR AREA E/SQ.FT.
essCO
Licensed Profional SIGNS ELEC CALF r ' �?.�Q
I-..;
4 tC� OWNER-HOLDER DECLARATION v- tl
rn a SPECIAL CIRCUIT/MISC
7 t-' IhercbyalRrmthatiamexempt from the Contractors License law(orthe - {
op following reason.(Section 70315,Business and Profession,Code:Any city or
O Zwhich TEMP.MEIT:R O�IJSf.
county requNea parmRroroorequialter, apmvydarrnlhh,ormitI
any structurepderto mentehat he
pursuant
to the
provisionorsuch s
of permit POWER DEVICES
file a signed statement That he b licensed punuan[m the provisions of the
3�G
Carapaces License Law(Chapler9(mmmencingwlth Section 700))of CIA. SWIMMING POOL ELECTRIC
p„ s(on3 ofthe Bumnessand ProfessionsCode)orthat hets exempt lhamfromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any v' OUTLETS-SWITCHESFTXTURES
O applicant for a permit iubjedstheapplicant to a dWP penalty of not more l ban I `—`�—�
five 1,a.. netoftheprdollars . _SQ. STORIES TYIIECON91RUCION
C NEW RESIDENTIAL ELECTR [(C:
IJ ❑I,as..net of the property,or my employees with wages as Their sole
7t mm(Sec.7044,will dothe ad rk,and Preeasi. structure
e:T).0 ContraIntenctors
orcome Law
O
sale(Sec. pply to an owner
df property Code:The Contractors License Law
does3$ who not
casuch roan owner ofpropertyhisobuilds or nemplyees,povidedonpomIft that such
OCC.GROUP RFS.UMTS
EEE whodoeents himself or hhowne.If,hoe,e,tha dthatsucr
Improvements Intended earofrempletih.If,hovrer-I iheerwill have 'TOT
Improrden of proving that
he did of buil por Imprhe ove
for purpose of sahave
tI ey�iurd s o neer of the pr a ditty,am exclusively
or improve facting oath licensed
ice se QTy. PLUMBING PERMIT FEE HOOD7ONE APN
(_J I,as owner of the property,am exclusively.anding with II Code:
rontncton to rorotnsctthe pmjeci(See 7014,Businessand Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT•WATER[EA) 1
Wilds or improvers;
thereon,and who centrads for such piojects with a
ropUTactor(s)licensed,pursuant to the Contradoes License Law. FEE SUMMARY
IL�J I am exempt under Sec. B&P C for this maven BACK FLOW PROTECT.DEVICE
'Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY - Y N_
• - Date RECEIPT a
WORKMAN COMPENSATION DECLARATION FTKTURES PER TRAP SCITOOLTA% Y N
❑I hereby affirm that 1 have o lmumne of consent to pytheure,ora RECEIPT N
certitlabC.Worken'C°mpewtlonlnsurance ora certifkd copythercof(Sec. GAS F.A.SYSTEM-1 UNC.4 ourf. TS PARK FEE Y N
38011,[f CJ ,
Policy p ° GAS EA.SYSTEM-OVER 4(EA) RECEIPT N -
Cany BUILDING DI VI. NFEES
omMCertined ropy is heed with tehed. GREASE/INDUSRL WASTE INTERCEPTOR' PLANCHECK FEtRewipt#Mcemnea ropy h mea with the sty,inspection aivhmn.
CERTIFICATE OF UM. PUON FROM WORKERS' CRFASETRAP PAID
COMPENSATION INSURANCE(Thi,sedlon need nut be completed lfthe permit h folone hundred dollanSEW F.RSAM1'ARY-5CORMEA.200FI'. [eWATER HEATER W/VENT/ELECTR' EN)tMVJIE I cent Thato the penon nce Inaoftman er(orwto I fhbe bj Isblued,I shag not employ any person In any manner eo ss t°berome wbjM to theWATER SYSTEM/TREATINGWorkers'Compensation lawsof California.Date PAID
� Z ApplicantNEW RESIDENTIAL PLMB.__SQ.PT. to
Z Z NOHCETO APPLICANT;If,after nuking this Certltlate of Exemption,you
H Code, ou=a forthwith
comply
with
proisinprovhlorooflha Lab be OTA
W Code,you mustfodhwlth comply with such provisions orthb pemal shall be _�
jdeemed revoked. - IN
Lu
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafOron that there Is a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z ante ofthn work forwhich this permit h h,ued(Sec.3097,Civ.Cd
at Lai 1,
02 lander'sName PLUMBING FEE
LL 1- Lenders Address s' Q'IY. MECHANICAL PERMIT FEE• MECHANICAL FEE02
OW Imdifyth.tl have read lhhappliatlonand featethattheabove hommaRon
S hromed.I agreetocomply with all city and county ordinances and mate Paws PERMIT ISSUANCE FEES PAID:
} relating to building rorolmctlon,and hereby authorise representative ofthis -
Zcity to enter upon the above•mentlomd property for bupectlonpu rpoees. I ALTER OR ADD TO MECH. + le Dale ROCeI t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,Jodgmcm,cost sand expenses which may In any way stems AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
aga Inst said City In consequence of the granting of this permit.
AIR HA NDUNG UNIT(OVER I Qocel CFM) CONSTRUCTION AX
Signature of AppBant/Contractor Data EKHAUST HOOD(W/DUCT) CONSTRUCTION X PAID:
HAZARDOUS MATERIALS DISCLOSURE
t Will the applicant or future building ocaopantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R el t#
mmerlal as deft net by the Cupertino MuNcipal Code,Chapter 9.1$and the - _
I lealth'and SafetyCode Sedlon2SS32(a)? HEATING UNIT(OVER 100,000 BTU) T TA .
Yes f�No
Will the applicant orfutum building occupant use equlprrr:nterdevim VFN7ILA?TON PAN(SING LE RESID) ISSUANCE TE
which rout haaardoue air mnlaMnanbade0nad by the Bay Are a Alr pp
r
Quality Management D❑istrict? BOILER-COMP OR 100,000 BTU) P N I D
4 Yea E No
have mad the Nazar uus materials requoments under Chapter 6.95 of BOILER- OMP(OVER 100,000 BTU)
the Callfumla Health&Safety Code,Sedlore,25505,25533 and 25534.1
undersand that if the building noes fit not currently have a tenant,that it h my NEW RESIDENTIAL ME CH. SQ.FT• NOV — � 17x71
responsibility to notify the occupa of the ratio lremb
enwhich=at be mota�Q(J•�
prior to Issuance of a Certificate of Occopa nry. �r
I`(Y Ur rtH ✓JJ/��ny
Owner or authorized agent Date ISSUE
' 70TAL
OFFICE COPY,