22190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
2P V7 LA-s owbAs C--r. 22190
�ne^ro sate: one: - A A A
�d-aja,� C 1MN JA'C..IC aNS U.GT)DN CITY OF CUPERTINO-BUILDING DIVISION /,o-'7/ � ` ,
contractors Name: Lie.No: APPLICATION / PERMIT J
BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engincer: I, Lk.No:
�k nQ QTY ' - ELECTRICPERMIT FEE BUILDING PERMIT INFO.
Address:'O)� J1 LLU� _,C. &VL CI`M\6L PERMITISSUANCE `i, EJ ❑ 11LICENSED CONTRACTOR'S DECLARATION l�J
Ihereby affirmthat l am licensed under provisions of Chapter 9(comment APPLIANCESRESIDEbNRAL JOB DESCRIPHON
l'ngwith Section 70M)of DiAslon3ofthe Buslnesaand Pmfe msCode,and my
icera,el,in Tali ddfect. I p PANELS /' �E•�
License CI ss Co # O (�
Date — — Contractor
ARCHITECA DECLARATION 201"1000 AMPS
z4�7 OVER IODO AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
0O 7 [understand mypkns shall used as publicremrd s.
qC SIGNS ELECTRICALif
a��j Licensed Professional ,
<Z. OWNER-BUILDER DECLARATION
I;n eFfi SPECIALCRCNT/MISC
�.., ]hereby affirtnthat l am exemptfrom the Contractor's License Law for the
'0O_"� following mason.(Section 7011.5,Business and Professions Code:Any city or TEMP.METER ORIOLE[NST. '
F�I"� countywhiehmlaIm,a permit tomnstroct,alter,improve,demolish,or repair
S �a¢ any structure prior to its issue race,also requires the applicant for such permit to POWER DEVICES
�e�U file a signed statement that he k licensed pursuant to the provisions of the
$u• Contractor,License Law(Chapter 9(commencing with Settlors 7000).f Divi-
SWIMMING TOOL ELECTRIC
F�O� sion3olthe Business and Professions Code)orthat he is exemptthmminnand VALUATION
uhSn the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
¢i applicant for a permit subjects the applicant to a civil penalty of not more than O
G c five hundred dollars(SSOO).
❑I,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR so Fr STORIES TYPE CONSTRUCTION
7� compensation,will work and the stmctureis not Intended or offered for -
p sale($ec.704#,Business and Professions Code:The Contractors License Law
S$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who it.,svch work himself or through his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearafcompletion,the owner-builderwill have
flILkmden of pmving that he did not build or impmvn for purpose ofaik.). QTY. PLUMBING PERMIT FEE
U I,as owner of the property,am exclusively contracting with 11«nsed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to ronstmot the project(Sec.70K Business and Professions Code:
The Contactor',LI«nae Law does not apply to an owner of property,who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve therron, and who contracts fns such p\ojects with a
tt+dor(s)licensed pursuant
to the Contractor's License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
I_I I am exempt under See B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
®
Owner - Date _ BEClOppp
Wffim ce
ORKMAN COMPENSATION DECLARATION FD(TVRFSPERTRAP SCHOOLTAX Y_ N_
certi1111 hereby arthat 1 have o certificate of consent m tnsure,ora RECEIPT M
ficate o(Workera Compevationlnsurance mce
artifled copyopy thereof(Sec. GAS,FA SYSTEM-1 INCAOUTLETS PARK Feil Y N
3800,labC) '/ q
�
Polley# Iaa Ie7ST—/� GAS EA.SYSl'FM-OVER6(EA) RECEIPT#
Cram BUILDING DIVISION FEES Cedlfnd copybhereby famished. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
' IG}Cenlfled ropy ia(Iled with the tlty lrupe<ion division.
•^l CERTIFICATE OF ESEMPf10N FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200FT. Date Remi t#
Rhlssection need not be completed If the permit k forom hundred dollars
(8100)mless.) WATER HEATER W/VENT/ELECrRENERGY FEE Y_ N
I certify that in the performance of the work for which this permit Is issued, '
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compereation Laws of California.Date PAID
O Applicant Date Remi t#
Z NEW RESIDENTIAL[RMB. �}T.
Z NOTICE TO AITLICANT:IL ager making this CertBicateof Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provblons orthis permit shall be BUILDING FE'
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M O Iherebyatfire,that them it; m
a nstrualon lending agency for the perform TOTAL: ELECTRIC FEE
Z arm of the work for which this permit it;Issued(Sec.309'7,Civ.C.)
00 Leradera Name PLUMBING FEE
LL Lender.Address QTY. - MECHANICAL PERMIT FEE -
O W 1 rditythat I havereadthisapplie,tionand state thatthe above Information MECHANICALFEE
CL i,correct.l agree to comply withal)crystalmunty.mmances and Asia laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorlu representatives ofthts
city to enter upon the above.mentioned property for inspection purposes. ALTERORADDTDMECH.
Z (We)agree to save,Iradertai and keep harmless the City of Cupertino Date. Receipt#
V against Is illt( ,jsdgment,, and ex Peter whicheryin anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) 'SUBTOTAL:
againstinspras r,u ceofthegattingoft emit.
- ��/ AIA HANDLING UNIT(OVER IO,000CIM) CONSTRUCTION TAX
Igmture of Applicant/Co raaor Date EXHAUST HOOD(W/DLICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous I MATING UNIT(TO IMWO BTU) Date Recef t#
material as defined by the Cuperta.Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER IW,WO BTU) TOTAL :Fql
❑ Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSI�ARCE DATE
which emit larardou,air contaminants as defined by the Bay Area Air
Quality Management District? BOILGR-COMP tlFN OR 100,000 BTU) MAY V0 1
4 !({]{]1
r
yr, ❑❑No
have read the hazardmua materials requirements under Chapter 6.95 of BOILER-COMP 100,000BN) '
the California Health&Safety Code,Stolons 25505,25533 and 2ti34. 1
understand that if the building does not currently have a tenant,that it 1,my NEW RESIDENTIAL MECH. SQFT. a6 f4naearj�
responsibilityto notify thenecupant fthe requlremetiawhich most be mat
Pus
aof rificate,of parry.
T
OwnermauthoriSedagent Data TOTAL: I ISSUED BY:
OFFICE COPY