22390 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification r PERMITNO.
$a Ic). a,: x eP5 CrZE� au/P ' 22390
wnenO"asll.ame: ��� .p-p�J p� one: q A
� R� 2�'V'-`(7 CE�2 31 CITY OF CUPERTINO-BUILDING DIVISION
Contractofe Name: c.Na. APPLICATION /PERMIT L
BUILDINGS.ECTMCAL-PLUMBINGMCCHAMCAL CATEGORY T'Q9L�
ect/ - Lie.Na CON(t:
�' TYib '4ELECTRiC PERMIT 'tI� ([ tt1`i FEE tt 'i`" I,UIBDINGPERMIT•INFOI°J'•
Addrcse: eIB�VN!-)I V/of -CI .. ,.''r
W( PERh17TI55UANCE t/.e
LIC ENSEDCONsed un 'BDECLA RATION APPLIANCESRFSIDENTIAL
I hereby affirm that( ivlicensedundernems provisionsof Chapter9(commenn OB DFSCEIr110N
Ingwlth Section 7000)of Divlmon3oHhe Bumneasa dPmfessionsCode,and my
limrx is in full( and effeet. , ` PANES I
cues LM.N .J TTQ,
ate Contractor G ,IVI� UP TO 200 AMPS
ARCHITECT'S N,-,' 201.10MAMPS ,
XZ ]understand myplawehallbeuxdaspubllcrerores. OVER1000AMP5 - SQ.FT.FLOOR AEA S/SQ.FT.
Et (� Licensed Professional SIGNS ELECTRICAL -
<<�6 OWNER-BUILDER DECLARATION SPEOIALCBRCUIT/MISC '
(hereby afflrenthat l am exempt from the Contractor's License Law for the
ppfollowingreason.(Section7031S,Bualneasand Profession.Code:Anytltyor
0 - TEMP.METER OR POLE INST.
F countywhic m'qulmaper tWmmtruc Ater,lmpmvgdemolbh,orrepalr �O y
gY any strum cture prior to its husuance,also requithe applicant forsuch permit to POWER DEVICES
Vfile a signed statement that he,is licensed pursuant to the provisions of the _ -
Ow30
fii Contractor's License Law(Chapler9(rommencingwithSection 7000)ofDivi. SWIMMING(Y)OL ELECTRIC thehas t fo Bumnvsand Pmfemion. Any
rlation f Secmpt therefrom and ALUATION
<� the(scab for the alleged exemption. Any tto violation of Section no en ou any OUTLE7SSW(TCI IF_SFI%7l1RFS
applicant for a permit Subjects the applicant to a civil penalty of no morethan
five hundred dollars($500). - NEW RESIDENTIAL ELECTR IT.
�1,as owner of the property,or my employees with wages ea their sole �'' ' STORIES 7YIaL CONSTRUCTION
compensatlon,will dothe work,andthenmeure b not leterdedoraffered for -
5 O sole&,70K Bualnev and I-mies ims,Code:The Contesdoe.License law
does net apply to an owner of property who Wilda or improves thereon,and - OCC.GROUP RFS.UNITS
CC.. whodoessuchworkhimselforthmgh Msownemplayeea,provldedthatmch
Improvements arenot intended proffered forsale.If,however,the building or TOTAL: (
Improvement Issold withinonerarofcompleton,theawne,bu0derwllHuvs
tk0jfurdenof provmgthat hedld nes WOd orimpeave for purpoxofsals.). QTY, PLUMBING PERMIT, FEE
u FLOOD TONE APN
L as owner tr the property,am exclusively Business
and with Professions Code: PERMIT ISSUANCE SL spa
TheounColprsto mrtawnsect La doe(Sec.70,14,apply t am owne fprert Code: [Jai -
Wil Contractor's License Law does nM apply ci an owner of property who ALS-DRAIN&VENT-WATER MA)
Wilds or Improvse tpursua and who mntrecta for such p(ojece with a ,'FEE SUMMARY
,JNafTacto"exe pt under Smnt
the Convactols License Law. BACK FLOW PROTECT.DEVICE
LJ I am vamp[under Sea B &P C for this reason
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N.
`
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION tt
Of
hereby affirm that I have a certificatensure
at consent to eetf-I ,orFIX.Il1RES PER TRAP a Cr SCITOOL TA% Y_ N_RECEIPT N '
ttrtificate o(Workers'Compema[lon lruurance ora cenl(led mpythereof(Sec.
�� I'ollryN .Z GAS G.SYSTEM-t INCA OUTLETS
LETS PARKFEE-, Y_ N38M labCJ CASEA.SYSTFM-OVER4(FA) RECERTM
Comy 1"4 BUILDING
DIVISION FEES
ertiftedop arcyIs ed, GREASE/INDUSTRLWASTE INTERCEPTOR PLANCHECKFEE
Y� stied copy b(lied withth the city inspection division. -
CERTIFICATF.OPCYEMPFION FROM WORKERS' GREASE TRAP PAID [y
COMPENSATIONINSURANCE SEWERSANITARY-STORM FA.200FT: Date Recei IN �Is I�
(Thlasecte n need not be completed If the peremit b forma hundred dollars
($100)orless.) WATER I TEATER W/VENT/ELECTR - ENERGYFEE Y N
I mrtl(ythat In the performance of the work forwhich this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Wmkers'Compensatem Lawaof California.Date PAID
Z ZNOTicant
ICETO APPLICANT:It,after ma king this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ,Ff. Date Recei t#
FO' should become subject to the Workers'Compensation provisions of the Labor TOTAL:
� U) Code,you=at forthwith comply with such provision orthes permit shall be BUILDING ••E 1
j deemed revoked.
W F3 CONSTRUCTION LENDING AGENCY, .• SEISMIC FEE .G
c
CL Z Ihereby affirm that there b a construction lending agency for the perform, TOTAL: _� E'L'ECTRIC FEE a^ -
7 ance of the work for which this permit b ixued(Sec.3097,Civ.C.)
U O Icndeea Name PLUMBING FEE
H Lendm's Add QTY. 'MECHANICAL PERMIT FEE.
LL - MECHANICAL FEE
O W Escortcortifed,
thatlhaveready with ais llcityndcounand tyordinaethat the abovedmateEnfom aaw.tion _
S Is mann.Iugreemcomplywlth all city and musty ordinances and mate laws PERMIT ISSUANCE FEES PAID: -
} relating to building commactlon,and hereby authorize representatives otthis '
f-' Z city to enter upon the abovereentlonM property for WpMion purposes. ALTFRORADDIDMECH.
_ (We)agree to save,lndemnl/y an d p hamNess the City of Cu Penton Date Receipt#
all tBabil s,p dgments,coma n pensee which may In any way acerae AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL:
' ag In said yIn. . uenreo 'etingmthl permit.
If AIR HANDLING UNIT(OVER IB,mocFM) CONSTRUCTION TAX
of ppOca /Contrctor Win ExHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALISCLOSURE
W7' 1,h,eapplicant or future occupant store or hand is hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
tosdefined bythe Cupertino Municipal Code,Chapter 9.17,and the witSafety Code r+.-u Section 25537(x)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA'Z'E ,
which emit haaardous air contaml®cats as defined by the Bay Area Ali
Quality Management District? BOILER-COMP DEB'OR 100,0W BTU) - Pte•
Yes No
have read the hazar ous nu/eriab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU).
the California Health&Safety Code,Sectors 2550.5,M533 and 75534.]
understand that if the building does not currently have a/enant,that It is my NEW RESIDENTIAL MECEE • SQ.17.
responsibility to notify the ocmpant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. taa.{pCaperinw
Owner or authodu-d-agent
Date ISSUED _7Yl{N1WiS6Rs/
TOTA1,
OFFICE COPY