22392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldhax Project Identification PERIMIT NO.
Building Address: 22392
vwnera name: �T Phone��:: - - APPLICA'IIONSUBMI'F1'ALDA'1'E
r ofok 2',7.5 l�'••ab CITY OF CUPERTINO-BUILDING DIVISION
me: / APPLICATION / PERMIT
R/ � G HQ - CAIT]GDRY ICOMIROk'p��/Q
RUILDINGELECIRIG4PLIIMBINGME CHAMCAL
�rchltetl/Engineer: LTC.No:
1 QTY �'�ELECTRIC.PERMIT;'; t, FEE '' �,• (BUILDING PERMITIINFO
Address: r��mn mix.n
' PERMIT ISSUANCE , S- � ❑
LICENSED CONTRACTOR'S DECLARATION
Ihercby affirm charism licensed under provisions o(Chapter 9(commnc- AI'DOANCESRFSIDENTIAL 08 DESCRIPTION '
IngwiNSection )o1 DlWslon3oftthee B�uMsesess1andd PProff MidoesCoic,and my ���
I.Litt'eaiCSss ll;o ldcl.Y. .. / 7 /v! / PANELS,
V�-/
Date ' 9i Contractor UP TO 700 AMPS
ARCHITECTS DECLARATION 701-10D0AMPS
q�++tt0 Z I undenhnd my plaru ahaB be used as pubhc mrords. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.F7.
C Licensed Professmod SIGNS ELECTRICAL /1 s�P I1/
< 0a Vv
<c. OWNER-BUILDER DECLARATION
m SPECIALCIRCUIT/MI.SC
7 p, 5. a,nua.( ecdom 7 31.5,Business fro a d Profeault License Law car chr
oo 8
following ntyreason.i tlon7031.5, mtmdandPmfessl , Code:Anytltyi-
OZt, TEMP.MEIPR ORIOLE INST.
county which requlree a permgro coremquir sthea ponce,demoish,orrepao
'11y anystrocture prlortols Issuance,also requ(rcstheappliant forsuch permiuo POWERDEVICES
K a file a signed rtatemeet that be s Ilanaed pursuant to the provisions of the
3w Contractors License Law(Chapter 9(commencing with Section 7IX0)of DWI. VALUATION
HBO don3,flhe Business and Profemimu Crede),rthat he fit exempt therefromand SWIMMING IDOL ELECTRIC I
y.' the bass for the alleged exemption. Any violation of Section 70315 by anyI''
<�
applicant for a permit subjects the applicant to a civil penalty of not more than uD OUTLETS-SWITCHES-FIXTURES "Mc
c O five hundred dollars MOO).' BTORIFS. 1••, TYPE CONSI'RUC'IION
NEW RESIDENTIAL ELECTRSQ.fT, �^1
�n ❑I,ea owner,(the property,orhe employeeswith wages r their sole 'i �•. L E D
C < compensation,wills,theworoxf.ihessude:TheC ntrended or offered.La,r E
$ p sale(Sec.7614,Bueknsand Profmlons Cade:TM Contntlole Littnse Ear .
I $� does not apply toanowner of property who Wilds orimproves thereon,and ITS
0.0.
who dons such work himxl(orthraugh hlsownemployeea,provided thatsuc •�j>�h_ � 'O T '
Improvements are not intended oroffered for sale.If,howeveq the bulldingor TOTA h, .[ V
improve"ntssoldwhhlno neyear ofcomplMloMlheowner-bulde,wllC. _ ��p �'�j
tfr urden of proving that he did not build or improve for purpose°fsakJ. QTY,( PLUMBING PERMIT, `y 1 APN
LJ I,as owner of the property,am exclusively contracting with licensed pp3(MITISSUANCE
IAt
contractors to construct the ponied(Sec.7614,Business and Professions Code:
TM C,ntnctor's License Law don not apply to an owner of property who—AL1IIt-DRAIN&VEM=WATER(EA)
Wilds or improves thereon, and who contracts for such projects with a
culapIcor(s)licensed pursuant to the Comradori License Law. I ,','FEE SUMMARY ,
II LJ I am exempt under Sec. B&P C for the mason BACK FLOW PROTECT.DEVICE y r)urGlPr ciPS i
DRAINS FLOOR ROOF,AREA,COND. I SANITARY _N-- N
Owner Date - RECEIPT I--
WORKMAN COMPENSATION DECLARATION FIX.FURES PER TRAP SG TOOL TAX Y N
j Q[hereby affirm that I have a certificate of consent t°self-Insure,or a I RFGF-1PC M
mniflcate°f Worked Compensation Insurance ore ttnlfled ropythemof(Seel GAS FA.SI'S'1'F.M-1 WC.40IITLETS (PARK F[E Y N
3BOQ Lab C.) 1
ij Com at - GAS EA.SYSTEM-OVER 4(EA) RFCEIPFN
Y - I BUILDING DIVISION FEES I
C^nines copy is herebyth the city I CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE 1
Cen0led copy s filed with the city Inspection division. �7
CERTIFICATE OF O(EMPFION FROM WORKERS' IGRP-ASE TRAP
I PAID? (�
COMPENSATIONINSermitb IS;RFE EWER -STORM PA.XIOPT. I Date : Receipt 371.,E
(I'hlasecti,n need not W completed((the permits for one hundrM dollars
(6100)or leas') WATER HEATER W/VENT/ELFCTR ENERGYFEE' Y N
I certify that in the performonceaf the work for which this permit h ssu W, 1
I shall not employ any u n e in any manner so as to become subject on the WATER SYSTEM/1RPATING I PAID
Workcra'Compensation Laws of California.Dat• _
O Z Applicant NEW RESIDENTIAL PLMB. SQ,FT. I I Date Retmipt#
_ZO NOTICE TO APPLICANT;If,after making this Certificate of E ere 'iogyou 1
should become Mal,rd to the Workeri Compensation provisions of the Labor I TOTAL:
F N Code,you mu at forthwith comply with such provsl°ru orths permit shall be I I
. j deemed revoked. BUILQIN�;FFE ['i Y.G�
ao CONSTRUCTION LENDING AGENCY 1 SEISMIC PEE
I herebyafnrmthat them samr,stmMOn kndingager agency for the perform ELECTRIC FEE '
M Z earn of the workfor which this permit s Issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name i PLUMBING PEE
LL F Lender's Address IQI-Y.1 'MECHANICAL,PERMIT. FEE IMECHANICAL FEE
OW ImAllythatl have mad this appgcittlonand statethatthexboveinf,rmationl
C is cored.Iagree to comply with all city and county ordinances and slate laws I PERMH ISSUANCE 1 S FEES PAID: ,
} relating t,Wilding construction,and hereby authorio,reprnentanvn of this
Zdty onenter upon the above onperty far inspection purposes. I ALTER OR ADD7O MECH. 'Date RCCeI t#
BY I a e o save IndemNfy n d p harmless the City of Cupertino P
V again It s,judgments d and ex nsee which may In anyway accrue AIR HANDLING UMT TCO l0,OD0 CF'M) I SUBTOTAL: I
agal t tyln coned( lthe a 'oegofthls permit.
4 z-� , AIR HANDLING UNIT(OVER IO,ODOCFMI CONSTRUCTION TAX
Signature,!Applicant/ ntra Or Date •� IXHAUSTHOOD(W/DUCT) I CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will theapplicantorfuture building occupant atom or handle hanrdoua HEATING UNIT(TO 100,000 BTU) I I Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
I froth and Safety Code Section 25532(a)7 HEATING UNIT 100,000 BTU) I I TOTALJ..1. ��
my. , MN. 11.
Will the applicant or future budding occupant use equipment ordevicne VENTILATION PAN(SINGLE RESID) I ISSUANCE DATES
whx,h emit haaardoua atr mntaminanb as defined bythe Bay Area Air
Quality Management Dished? BOILER-COMP(3HP OR 100,000 BTU)
'? Yes �No PAID
`!'have sad theM1aza ous matenas requlremnnh under Chapter 6.95 of BOILER-COMP(OVIB 100,000 BTU)
the California Health&Safety Code,Section9755D5,25533 and 25534.1 DEC ,- .� 1991
understand that ifthebuildingdo es mocan only haveatenanL that ltsmy NEW RESIDENTIAL MECH. SQ.IT.I
responsibility to notify theOLmpant of the requirements which most be met I I 7
prior to issuance of a Cecil Bate of Occupancy.
CII Y r v�UPryt1tl9llvU ``J
Ownerm.tithodaedagent Date ^f L,�� ISSUED BY- �• �`_ L/`��I .3W/
TOTAL —l. p77
OFFICE COPY