22076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I - PERMITNO
Building Address-
1012 22076
7 � l�E (�' C T° 7& 1 i -
Uw era name1: l'� At'VUW IIUN'etllal UIIALOAIh
S LIB �kel- I,I�U OF CUPERTINO-BUILDING DIVISION
Contractor's Name: y LIcPPLICATION I PERMIT
DING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROr
Ar h�,/.E�nI�+�j4` LTC.N.
IC?
— '�"'—�-�"� 614,4 4v '��'.�,ELECTRICPERMIT', i ' f �f FEE •,BUILDING PERMIT INFO J•, ,
Address: ��
' PFdtMB7I55UANCE IZx .
LICENSED CONTRACTOR'S DECLARATION L� j
Ihercby alfbm that lam licensed under prwblona o lChapter9(rommmc-I APPWANCESAE4DENTIAL JOB DESCRIPTION
Ingwlth SM1ior7000)of Dlvisioa3oflhe Buslnessand PrufrseionsCc de,and my
Lcense Isle. force and sic.It PA
FIFSS 1^ � ROD.I w
lures Chas LICX l 4 ' `�/F-' l 1 l
Date Contractor IT W200 AMP'S
ARCHITECTS DECLARATION 1 201-1000AMPS
QZ I understand my plarushall be used as public mcrnde. OVER IWOA�I'$ _ � SQ.P!'.FLOOR AREA f/SQ.Fr.
spa ° jjr••]c'-B'_/ . l.a fl' �'J a '� 63 7�(-
fL Licensed Pro(essiorul - SIGNS AL. / '
6 OWNER-BUILDER DECLARATION 3 g.EC)A �'1R,^UIT/MI I II"� �„fI V 1 -
Lo, 7 _ I herebyaffirm that am exempt fromthe Contractions Llcenw Lawforthe
O Z t- following meant.(Section 7¢115,Business and Professions Code:Any d P or I TEMP.METER Oft POLE INST. /�5./'/,� � -
r<� j county which requirna permit to rorutruv,alter,improve,dennlish,orrc air F�ppTcO RR
cG any structure prlorto its Issuance,alsorequlrmthe appEcantforsuch permit to POWER DFQ.ATF-�a+�-� -
C P 6 Ole a signed statement that he is licensed pursuant to the provialoro of the __ y 1
SOSComment'.Llcamelaw(Cha er9(mmmencin itle Section7000)o(DWI �-- �-•1
Men3oftheBusiness and ProfeseloruCde)orlhaghe b exempttherefromand SWIMMING IDOL ELECTRIC L-�7 L�17ON .
the basis for the alleged exemption. Any violation of Se viol,70315 by any �
6
applicant permit P applicant Penalty o n IfILETSSWITCHESFlXTLRFS
(hundred eMt$500). hea 11 uoa civil It (not
(Ise 11,as dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES - T'YPECONSIRUCTION'
❑I,ti owner of the property,or he employees with wages r there Bolo I
mpeneatlon,Businesseworkandthestrode:Th Ccent otin'or..L fort I I
O sale(Sec.7614,Business and Pro(�loro Code:The Contractote Liceme Law I
' $$ does not apply to an owner of property who halide or improves thereon,and OCC.GROUI' RIS.UNITS
0. who does such work himself orthrough his own employers,provided IN teach b
I Improvements are not Intended oroffered for sale.If,however,the building or TOTAL: l a�
Improvement Ia sold within one yearofcompletlon,the owner-builderwlll:.
t eno(proving that he did not build or lmpreve(or purpose of wle.). (QTY: I � , PLUMBING PERhI1T FIE, EIADD ZONE APNI
as ownare"he property,am exclusively mntravil,g with ticensed PERMIT ISSUANCE Il/� may.,
contra tororuWRthe projM(Sec.7094,Businemand l'rofesalom Cdea , ialt� -
71u Contoi License Law does nv apply to an owner of propery who(--'— ALTER-DRAIN&VENT-WATER(EA) y--�
Wilde or Improves thereon, and who rontram for such p(opcts with a I La�
t ctcuts)ueenadpursuant to the Contnvor'a Lima.Law, I , FEE SUMMARY',,
yLlfa[r exam under Sec B&P C or thb reason BACK FLOW PROTECT.DEVICE I t '
J pt r�ll'rC1IW,�'FI'S
_
Owner Date DRAINS A,FLOOR ROOF,ARE COND. I I SANITARY Y N
RFCEIP1'M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP ''') SCHOOL TAX Y N
❑I hereby affirm that I have o lonagae of consent to sel(-Inerro or c. l I ^^x�r1�a RECEIPT M
certificate of Workem'Campemuauonlrlsunnreora rertl(led ropythereof(Sec. I GAS EA.SYSTEM-I INCA OUTLETS I l l.fa' (PARK FEr' Y N
3900,Lab C.) s
Coro env GAS EA.SYSIPM-OVER 4(EA) DI GDIV
I I BUILDING DIVISION TEES
�CertlRd ropy is hereby banished. I GRPASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
❑Certified ropy is W filed with the city pectlon division.
CERTIFIGTEOp EXEMPTION FROMWORKERS' I GREASE TRAP I PAIDL4-7G-q I`C'30
COMPENSATION ISEVIER-SAMTARY-STORM EA.MOLT, I Date Recei
(fhisxvlonned CO be completedNINSURA V(ororie hundreddollan Ptg � Sd
($100)or less.), 'NERGY FEE Y N
certify lo board, I IEAT'LB W/VENT/FIFG TR
I rtify(hat the performance of thework forwhlch this permit is
Ued,
I dull not employ any person In any manner m rs to become eub)ect to the
Workon'Compeneatlon Usys of Gllfomfa. Das• wATTR SYSTEM/TREATING I PAID
z Z Appilcmt
- -_ NEW RESIDENTIAL PLMB. SQ.Ff. I DatC ReLeiplM '
Z0 NOTICETOAPPLICANThe after makingiereattorprtao(onard'lon,you
H •shauldberomat f.ftcttnthe Workers'Comprovislnprov6lom o(the Labor TOTAL:
OC
N Cdc,you must forthwith comply with such proWioru orthb perMtahall bcl I. BUILDING FEE 9���
W j dmmed revoked. o
IL F3 CONSTRUCTION LENDING AGENCY I f SEISMIC FEE -1. t0
CL lberebyafBrm that there is a construction lending agency for the perform (�
M ance of the worklor which this permit b luued(Sec.M97,Cie.C.) TOTAL:,1-2 O.C'J uLGCTRIC FEE G`7a�1
L) O Lender's Name ;PLUMBING FEE
LL H Lender's Add, (QTY. t MECHANICAL PERMIT ' I' FEE MECHANICAL FEE
O W Icertlfyt love ren thb appbretlonand satethal lheabovc lnfomutlon I
C is rormct ugreeto com y with all city and county ordinances and elate laws] , PERMIT ISSUANCE I1Z C� (FEES PAID:
relatln obulldingro mct dhereby authorize cep talivea of thh IQ �1
Ztltylo ter upon the abov toned property for W purposes. l ALTER ORADDTO MECH. G�i-1
(Val Brea to save,1 mnrfy an d keep harmless the 'Ity of Cupertino Date ReeeipNl
agabu;lia illtiraj nts,cvnsand expenses which n Inanywaye a AIR HANDLING UNIT(f010,wo CFM) I 1 SUBTOTAL:
egernstiel Ct ro xquse ofth.gnirti. AIR(4Af HA H .N ----- -
NDLNG UNIT(OVER 10,000 CIM) I (CONSTRUCTION TAX'
goat of pllwnt tractor to�'-f--t/qz IXHAUST HOOD(W/DUCT) I CONSTRUCTION TAX PAID:
HAZARDOUSMATF.RIAL S
Will the applicant orfutum building occu pantstore or handlchazardoue I HEATING UMT('f0]00,000 BTU) I�.� Dale RCCCID[N
.terlal as dented by the Cupertino Municipal Cde,Chapter 9.12,and the
Healthand Safety Cd,Sectlon2S532(a)7 I HEATING UNIT(OVER 100,000 BTU) I TOTAL:
1:1 Ye. 1]No
Will the app Ecuntorfuture building onvpant use equlprrcnr ordevices ( VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which,mithazarom air rontaminantaas defined bythe pay Area Alr P-1110
Quality Mawgcrrcnl District? BOILER COMP OFI'DR 100,000 BTU) i
I-I Yes .�No d
`]'have read thchaza om materials requlremenb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) I u/ n c
the cehfor tsi Health&Safety Cde,Sections 25505,25533 and 75534.1 - bs 0 M �}Q
understandthaHfthebulldrngdoea mecureentlyhaveatenenpthat itismy, NEW RF_SIDENTIAL MECH. t SQ F1.I y
priors issuance notify CcAlfi ccupnnt of the
pancy. cements which muss be rot I �
prior m rvsuance of a Certi Ocate o(Ompanry.
Owner or authorized agent Date rII-7 rITESURD BY
TOTAL: f�•1�'i��-f
OFFICE COPY