22556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
On Bolin Proect Identification PERMIT NO.
Building Add oo e 22556
Al,r
secs arse: one ITONq
•
a voc-'C' CITY OF CUPERTINOLBUILDING DIVISION / Z ON ,— / ��SUBM11TAL DATE
Contractor'sN`me: Lie.N. APPLICATION / PERMIT 1
BUILDINGELECTRICALMLYMBING.MECHAMCAL CATEGORY CONTROL R
Archlte /Engineer: a Lic.Nee
' I; �� `'' �ti . �eBUILDING PERMIT INFO
'/ QTY ELECTRIC PER Ff FEE
Address: '`� . " ,ioei GL' PERMITISSUANCE 1:1 ❑ ❑
LICENSED CON ACTOR'S DECLARATION
I heretiefftrmthat l am licensed under provisions of Chapter9(comman APPLIANC 9 L ]OB DFSCRB'TION \
Iogwith5ettian 7000)of DiNa m3 ofthe BuNnsssandprofessionsCode,and my C'DNx�T�
license lsinfuR and died s/
License Clss Llck
Date te.#_ or ^A/I/ l T.Vs V
ARCHITECT' DE LARAT N '1000 AMT'S
r�Q z -I understand my plans shall be used as public records. OVER 1000 AM Z SQ.FT.VLOOR AREA '$/SQ.FI'.
�l Licensed Professional SIGNS ELECTRI
z
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
following reason. that lam exempt fromthe Contractor's License law for the
�0z eminlingrease (Section 7MI.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
'�I"'� countywhkh requires a permit to construct,alter,Improve,demolish,or repair
any structure prior to its Issuance,also requiresthe applicant for such permit to POWER DEVICES
C file a signed statement that he b
licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O Men 3 ofthe Business and Professions Cade)or that he la exempt therefromand VALUATIOIy
F G the basis for the alleged exemption. Any violation of Sectlan 7031.5 by any OUTLETSSWITCHFSFIXTURFS Y O s it O
applicant for a permit subjectsthe applicant Io a civil penalty of nal more than V
five hundred dollars hepr. NEW RFSIDENHAL ELECTR SQ.Fr,
❑I,as owner of the property,or my employees with wages r thele sok S F$ TW STRUCTION
G compensation,will do Businethework,and rof.iestrunurela CmitrendedoiameLaw L
❑
sale(Sec.7ply to alnower Professions CobuildsTh.Contractors Lereon Law
who dodoes Amessuchwork
such oak inserorthmgy so nemplelmproves ovided thatand - S
whodoernernaork not
orihroughhisownee.ILlu es,p r theb thatsuor
improvementi are not intm.ray a,.f,d forsake.IL however,thebulltling or TOTAL:
improvement usold withinoneyearofcompletionlhe owner-bullderwlll have '
tl(ek en of proving that he did not build or Improve for purpose ofsale.). QTy. pI,U11'IBING PERMIT FEE
Ltr L ae owner of the property,am exclusively contracting with licensed
contractors to corstmct the project(Sec.7044,Business and Professlons Code: MIT ISSUANCE'
The Contractors License law does not apply to an owner of property who ALTER-DRAM&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such plojects with a FEE SUMMARY
cgD[factor(a)licensed pursuant to the Contractor's License Law. BA«PLOW I'R077?CT.DEVICE
LI I am exempt under Sec. B &P C for this reason
R AREA COND, BAMTARY Y N
• Owner Date DRAINS FLOG ROOF, RECFIPTM
WORKMAN COMP LTVSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N—
❑I hereby affirm that I have a certificate of consentaudifi to pythemof ora RECEIPT M
3800mAiLab o(Workers'Compersatlonlwurance oracertifkd ropythereof l5ec. GAS EA SYSTEM-1 INCA 3800,Lab C3 PARK FEE Y— N_
Poliryq ...Z-- - AGCER'fp
Com any a GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
Certified copy is herebyth the
GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
1'�.lCertlRed copy is filed with the tlty Inspection division.
'!' CERTIFICATE OF E(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTDRM EA 20oFT - Date Re i t#
(This aectlon need not be completed lithe permit V(Drone hundred dollars
($100)oelessl WATER HEATER W/VENT/FLECTR ENERGYFEE Y N
Irertifythat In the performance of the work for which this permit is Issued, —
I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TREATING
Workers'Compensation lawsof California.Date PAID
O Z Applicant - Date Rerei t#
Z O NOTICETOAPPLICANT:ILakermakingthb Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.HT.
should become subject to the Workers'Compewatlon provision¢of<he Labor TOTAL:
CC N Code,you most forthwith comply with such provisions orthls permit shall has BUILDING FEE O
Uj 9 deemed revoked,
aCONSTRUCTION LENDING AGENCY SEISMIC FEE .59
I hercbyaffirmthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
O ance of the work for which this permit is Issued(Sec.3097,Cho.C.)
(� L.ender's Name :MECHANICAL
ING FEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE FEE
OW Icertifythatl haveread thisappBratfinand statethattheabove InformationC Is correct lLgree to complywlth all city and county ordinances and state laws PERMITISSUANCE ID:)- N relating to building construction,and hereby authorize representatives ofthis
� city to enter upon the above-mentioned property for Wpection purposes, ALTERORADDT'OMECH. e Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertinoagainst liabilities,judgments,embiried expenses which may In anyway accrue AIR HANDLING UNIT(TO 30,000 CFM) SUBTOTAL• -�
against said City In conae�ryemu fthe of ing of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) RUCTION TAX
fre AA/pp IiIccantt//CommetcT /^ 4D7ate'T EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicent or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety CodL&ctloo 25532(a)7 HEATING UNIT(OVFR 100,000 RTU) TOTAL63'
❑ Yes Q(I No ••
Will the applicant m future bcllding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous.I!to.Umur ants as dented by the Bay Area Air
silty Management Dist ct7 BOILER-GDMp(3I'IPGR 100,000 BTO m n n
Yea �X t NO
07 Ir !N Y
have read the haza( a materials rcqulrements under Chapter 6.95 of ROLLER-COMP(OVER 100,000 BTU)
the Califomla Health&Safety Cade,Sections 25505,75533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT JAM 2,� 1992
responsibility to notify the occupant m the requirements which must be met �a vv
prior to lssuanrro�f a Cs�rtifican,&O panty. /• 9
ero autNorbedaR gent � /^ a�y Z_ CII r CUPkt+Ilau
TOTAL: ISSUEDRY: 'A'l«-'
OFFICE COPY