22412APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALLPOINT PEN ONLII
Building Project Identification -
Building Address:
PERMIT NO.
22412
cess one:
a_
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /'PERMIT
BUILDINGELECTRICALML BING-MECHANICAL
'
c°no-. ,a • :Q—Lc.Na:
CATEGORY CONTROLN
.:'( 4BUILDINC'PERMIT INFO
.UI '.._. IT INFO 8'
Architect/Englnm . c. o:
,� , ,... a;'w C Ix" tet "(r r)p';,
.. EL_ECTRiC PERMIT.-"'�",
,. IM711
i:FEEt,",
Addrces:
LICENSED CO N
DCCLARATIO
- Iherebyaftlrmthat l amllcrosed underprovbions of Chapter9(commmc
ingwithset1onMOD)of Dlvislon3oflhe Businenand ProfnsionCode, and m
litnseis in 11f andeffet.
Lirenx Lic N
Date Contracto JJA
ARCHITECPS DECLARATION
I understand my plane shall be used as public records.
Licensed Professional A
OWNER -BUILDER DECLARATION
1 hereby a(Ormthat I am exempt from the Contractor's License Law for the
cwntywMch rcqulreaa penNt to covvuct, alter,lmprove, demolish, orrepalr
cmntingreason.(Sesape Bu tmdand Pimp i, eo ]e hnympair
anyatroctureuitemeits lhatecgabosedpursuant toto
file a algned aicens eLa that he b licensed pursuant it the tion 7 0D) of the
provisions
Contractor's License and PChapte,es Cosde)or le, withxetlon70r)of and
the basis3 of for the alleendexamptionC Any violation f exempt therefrom and
the blab for the alleged exemption. Any Wblatlon of Section 74115 by any
applicant fore perndt svbje is the applicant to a civil penalty does mreathan
five hundred dollars (SSrXB.
F11, a• owner of the property, br my employees with wages as their wale
°mpenwation, willdothe work, andthe strum m isnot intended or offered for
sale (Sec. 7044, Business and Pmfnslom Code: The Contractors License law
does not apply to an owner of property who Wilds or improves thereon,and
who doessuch work himself or through hisown employees, provided that such
impnevemenbare not Intended oroffered forests. If, howeverthebuildlegor
improvement bsold withinone)carofcompletlon,theowner-b iiderwill have
t)l,hundenof proving that he did not build or Improve for purpose of sale.).
"S aacaveer of the property, am exclusively contracting with licensed
contractors to mnstrud the project (Sec. 70K Business and Profession Code:
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such Ptojets with a
,�[actor(s)Ikensed pursuant to the CmtractorLLkense Law.
c LJI am exempt under Sec' B & P C for this reason
•..,. PERhBTI55UANCE •- .
.
❑
❑ ElACTOR'S
APPLIANCESRESIDENTIAL
JOB DESCRC710N -
/ '���
7
. PANES
LIE TO 200AHM
—
201 -IOW AMPS
OVER1000AMPS
�, n
5�rf. R
� � R
�a
%�/
G { II
'S/EQ. FT,
SIGNSELECTRICAL _
SPECIALCIRCUIT/MISC
t � V,�
TEMP, METER ORPOLE INST.
POWER DEVICES
SWNMI NG FOOL ELECTRIC
V�ApLUATION '
(� J
OUTLETSSWITCHFSFI%TIIItES
NEW RESIDENTIAL ELECTR.FT .
STORIES
.,
TYPE CONSTRUCTION
TOTAL:
,
(j'1'Y, ',;, '1�"PLUMBINCPERMIT'"'
",i FEE;'t
OCC,GROUI'
'
'RFS. UNITS
,�5,
PERMIT ISSUANCE '
ALTER -DRAIN& VENT- WATER (EA)
FT.oDDZONE
APN
BACKFLOW PROTECT. DEVICE
s! ''FEE+SUMMARY.''
(H11rellIn sees
DRAINS FLOOR ROOF, AREA, COND.
FD(NRES PER TRAP
-
SANITARY Y N_
- RECE117 N
Owner - " Date .'
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I haveper;sa o l rtunte of consent d spythemo ora
ofWorkers'Comperuatlonlnuranceorarertifled copythereof(Sec.
3800, �difiLab
Policy# C.) .
-
SQ'IOOL TAX Y_ N_
RECFTPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEC Y_: N
RECEIPT
CAS EA.SYSI'EM-OVER4(EA)
CnI
Cam an
CY
BUILDING DIV] SION FEES
❑ C ertified copy in herebyth the cityed.
' F1 Certified! copy b Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
Cot W completed
RhlsseNon need est W complied if the permit Is for one hundred dollars
($]Immly that
I mrtlfy that In the performance of the work for Mcht bpermlt le Wved,
I shall not employ any persynon an noon:, to the
W°rkcrs'Com �LL�asn i�s/�F ai�/f rob. x
Applicant
NOTICE. L tot after making o thisionlcateof Exemption, you
Compentlonprovbionrmit the s Lab be
Code,shoulo m 6stforthwith co ply with
Code, you mus forthwith comply with such provision or solo permit shall be
deemed revatrea. �
CONSTRUCTION LENDING AGENCY„
P^ Ibercbya(firm thatiherelsamrutrudlonlendingagenryfortheperlorrry
Lend e(the work for which this permit is Issued (Sec. 3097, Civ. CJ
Lender•:Name
LendersAdhatI - -
W � I cent. 14g I have read this apalatyand c state that tnances a Information
countyordinances
is turret. building
complywith and hereby reprcesandaatelaws
relating to building mmtrotlon, end hereby authorize reprcsentallvn of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmlese the City of Cupertino
against llabillties,/adgrrents, sand evpenses wh nuy loan way cerue
a aloe Ch iseque o(th granites of spermit.
sigruatu Applies, Com -dor D a
' HAZARDOUS MATERIALS DISCLOS E
Will theappllcaut or future building occupant stare er ndle hvallow
material as defined by the Cupertino Municipal Cole,Chapwr9.12, and the
HealthandSafetyC a tion 75534(.1)7 >
❑ Yes o
Will the applicant tum building ocmPaul use equipment or -devices
which emit hazardous air contaminants as defined by the Bay Arca Air
QualityManagement t'ct7:
4 a n No
h beread the baz materials requirements under Chapter 6.95 of
theerstan thatlith Safety Code, otcurrentlyh have a tend, that
'ueporudndthal notifloue ing oc=pces not currently haves tenant, slut h met
r priorto bauunllty to cis oats of of the requirements which must be met
Certificate
prior to fssuanre cats Ccrtl(Icate of Occvpanry.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE '
PAID ,
Date Remi tN
GREASETRAP
SEWER-SANI.f.ARY-STORM EA. 2DOFI..
WATER 14FATER W/VENT/ELECTR
ENERGY FEE Y N-
PAID '
Date Remi t#
'
WATERSYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ,FT,
TOTAL:
BUIL ING FEE
'5,5i 051
SEISMIC FEE
L
TOTAL:
ELECTRIC FEE
-
QTY. ', MECHANICAL' PERMIT
,FEE,,
PLUMBING FEE -
--
MECHANICAL FEE
'
PERMIT ISSUANCE
FEES PAID:
'
ALTM-ORADDTOMECH.
AIR HANDLING UNIT 10,0(ID CFM)
-
Date ReCeiptq
SUBTOTAL:
AIR HANDLING UNIT (OVER10,000CFM)
CONSTRUCTION TAX
EXFLIUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
-Date ReceiptN
HEATING UNIT iW,OW BTU)
TOTAL:
L%
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
-
'
(/
rs, � �
r
ISSIIEDO
BOILER -COMP DEEP OR 100,DM BTU)
BOILER.OMP(OVER 100,000 BTU)
NEW RESIDFN77AL kiCQi. SQ.Ff.
Owner or authorized agent - Date
TOTAL:
OFFICE COPY
O
0
7�GLJ 1l ab.
�arn,✓10� �i �0�vp �,
� LS
la�5e
Ir(�h.IUI �n
BLDG. INSPECTION DEPARTHIM
OWV er I\ \,\t\ SN
N1ag�erGra� �
PD �x 2415
Rw 9440�/-h
11�� 484350
zc-
ame. PO 3>10
� pLOT p
LAtfS
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.Y N i T �� STS L=a .AT D N_.