22677APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY
Buildln Project ldentiflc.Uan ,.
- PERMIT NO.
Building Address:
22677
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CUPERTINO- BUILDING DIVISION
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APPLICATION /,PERMIT
LDINGELECTRICAL-PLUMBING- MEC)IANICAL
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CATEGORY
CONTROL a
Archited /Engineer. Lk. No:
Ti.,
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tia,i LECTRICPERMIT.. ,i;rAddress
.,i'�BUILDING PERMIT INFO,,,'
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PERMITISSUANCE
L CONTRACT DECLARATION
m that I.D
er pr
Y' Pro" Pte
with on7"atlamlken3ofthe a Land Po Cha r9 (comment-
Ingwlit I fun7000)of Dlvfiect fiheguslnessandPa fessionsCode, and my
uanse lamfuua seared. ay 3m
01p
MPLIANCESRF.SDENI7AL
JOB DPSCRB'DON
,PANELS
U\JALE
T— `7ARCHITECTS DECLARAT`1ION � S
l understand my plans shall W used as public records
201 -I Il00 AMPS
OVER I ODO AMPS -
SQ:FT.FLOORAREA 'sm. FT.
SIGNS ELECTRICAL
Licensed Professional
SPFGIALCRiCUIT /MISC
OWNERe BUILDER DECLARATION
License Levi firths
Iwingrason.(hatlamexempHroessad
DIN -
[,�]
7EMBMEITRORPOLEINSf.
POWER DEVICES
Profctori
followwhich mn.(Sectiaemmtw, Bmtmdalt Ptmp e, emle hnydty or
anystm hmpNortosapermittomomqu ialter,Improve,tforsuah, er ttr any structuretatemeita Wt heir lice sed pursuant t theporsuchpeof the
file a added statement that he b licensed pursuant
1Sterna bl0D) of the
oVe P
E -
U �/
r it
d ProfemWn.
Ce"oftoeHusiree Law nd Profaskinscom) or that he is Sterna 700D) and
exempt therefrom and
SWIMMING POOL ELECTRIC
VA
the Wafiheau a alleged e Any violation n of
the baale for the alleged eaemthe applicant Any t to a(naltlon not 7031,5
room by any
permit subjects the applcant to a dull penalty of not more than
OUTLETS- SWITCHESHFIX URES
flue hundred dmlWrs ($500).
five hundred dollars
❑ L as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTS IT.
SQ''
STORIES
TYPE CON?RUC "PION
compensation, will do the work. and the structure b not intended or offered for
-
.sale (Sec 7014, Business and Pmfesslotu Code: The Contractors License Law
does not apply to an owner a property who Wilds or Improves thereon, and
who doessuch work himselforthrough his awn employees, provided that such
IXC.GROUT'
RES. IIN1'fS
Improvements arc not Intended or offered for sale. If, however, the building or
Improvement lssold within one yearof completion, the owner- builderwlll have
TOTAL:
'
treaders of proving that M did not build or Improve for purpose of sale.).
LJ L as owner or the property, am exclusively contracting with limned
contractors to construct the project (Sec. 7074, Business and Profession Code:
QT`Y,
„dpi,UMBINGPERMIT
FEE
FTppO TONE
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APN
V
PERMIT ISSUANCE
The Contractor's Llanae Law does not apply'to an owner of property who
Wilde m Improves thereon, and who mntracts for such pTlects with a
'copUadoKs) Licensed pursuant to the Contractor's License Law.
I am exempt under S,. B & P C for this reason
ALTER-DRAIN &VENT -WATER (EA)
't FEE SUMMARY
•'
BACK FLOW PROTECT. DEVICE
DRAIN &FLOOR ROOF, AREA, CORD.
FTXTlJRF_S PER TRAP
Y N
RFLPdIT R
Owner - Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a ormfi ate of consent to eel6lnsure, ar a certific amo(Workern'Com'p7evpathn laurance oorr a certified ropy thereof (Sec.
CJ -IO a .a d `
OL TA% Y N❑1
CAS FA.SYSfFM- 11NC.40ITILEfS
3ARY
FEE Y N
P.II0.Lab
Policy q ' ` (/ Z
RECERefI
GAS EA. SYSTEM -OVER 4 (RA)
Com anvTL� -%N
BUILDING DI VISIONIT[S
[]PCertlBed copy is herebyth to ity
Certified copy b (fled with the city Inpedlon division.
CERTIPICATE OF FXEMPFION FROM WORKERS•
GREASE /INDUSML WASTE INTERCEPTOR
NCHECKFEE
PAID
,
GREASE TRAP
SEWER- SANTTARYSTORM FA. 2WFT.
-
COMPENSATION INSURANCE
Qhtssectimn need not W completed If the permit is forom hundred dollars
Date RCC'el IN
WATER FIERIER W /VENT /I7.[CTR
ENERGYFEE Y N'
($100)orlese')
I mrtifythat in the peHormince of the work for which this permit is Issued,
WATER SYSTEM /TREATING -
.1 shall not em ploy an/ person In any manner m rue (o be� c to the
Worken'C pensati so I(ornla. Date l
PAID
'Date Recel till
NEW RESIDENTIAL PIMB. SQ.FT.
r,O
N'O C OMP CA ':IL after making this Certlflate of Fxemptlon, you
TOTAL:
a,. come subject to the Workers 'Compereatlon provulore of the Labor
Code, you moat forthwith comply with such provision or this permit shall be
deemed revoked.
BUILDING '•E
SEISMIC FEE
' CONSTRUCTION LENDING AGENCY
I hereby alfirmthm there is a construction lending agency for the per form-
ante of the work for which this permit Is bet ed (Sec, 3097, Civ, C.)
Lenders Name -
Leaders Aaama ,
1 certifythat I have read thisappiiationand statethanheabove Information
is correct.•] agree to comply with all dtyand countyordlnanceeand extelaws
relxiing to building conwdlon, and hereby authorize representatives of this
citytoenterupon the above- mentioned property for inspection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino
agalnstliab tes,pdgments, costsand expenses which may in anywayaccrue
against ea City In conaary ofthe granting of this permit
—3 '_g
TOTAL:
ELECTRIC FEE
-
QT Y.
'. MECHANIC A IL PERMIT
.'FEE .
PLUMBING FEE '
MECHANICAL FEE
PERMITISSUANCE a
O
FEES PAID: -
ALTERORADDTOMECTL
Date ReeClpta
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
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Ig reof Applk /Contractor Date
FXHAUSTHOOD(W /DUCT
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
.
HEATING UNIT (TO 100,000 BTU)
.
pate Rewi [#
' Will, the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
HFATINGUMT(OVER100,00031I1) -.
TOTAL:
Ifealthand Safety Code Section25532 (a)?
RRillM No
VENTILATION PAN (SINGLE RESIO)
_
ISSUANCE DATE
ill the applicant or few. building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yea . M No
i have rcad the hazaous material. requirements underChapter6.95of .
the Calif ornWllcalth& Safe yCode ,Sedion25505,25533and25534. I
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++fI�T14I91N�''
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BOILER -COMP DHP OR 100,000 BTU)
BOILER COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQdT.
understandthatifthebulldingsloesno t currently haveatenanq th;rt it is my
pdorto1b11Byleof CcAiti teo(tm(therequlremenis which most be met
prior tm ksuance ola CertiBate of Occopanry. I
✓•pe
Owner or authorized agent Date
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TOTAL:
t
UEDBYr_�V
OFFICE COPY