22294APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification • .
PERMIT N22294
Bu11dD4dQrSysa' l � BY/✓ `a"ai `� i t �f^"
(J ��� �� f�� )�
wnersName: one:
_
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAI PLUMBINGMECHAMCAL
DATE
mtradora u=. Na:
�O tti G G.
CATEGORY
CONTROL N
Architect/Englncer. Lk. No:
G _ N7
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
r�
J4 fxC
PERhITISSUANCE �
LICENSED CONTRACTOR'S DECLARATIONON
f hereby affirm that lam licensed under provisions of Chapter 9(mmmm
ingwlth7OOO)ofDt�sion3oftheRustnemandProlemionaCadeend my
licenseeIs 1.full force and effect
Lidnse Ch® LION
AI'l'fAANC1SRESIDENITAL
JOB DESCRIPTION
p/%4it-w
PANELS
Date 4�2 N Contractor-
ARCHITEC'SDECLA TION
I understand my plans shallbe used as public records.
Licensed Professional
HI1-
OV
SIG L C
SQ. FT. FLOOR AREA
ZLj
Q.p
51/Sy.
7 -1 r LZ
S+ECIAT/MLSC 7771<111
OWNER -BUILDER DECLARATION
law fmthe
TherebyoormthatTam31.5,
TEMP. METER ORIOLE INST.
BsinesseContnctoraLlcerse
Business and Professions Code: Any dtyor
following moon. recla Seda permit did,esth Improve, demolish, or repair
county which regokna permh toconstruct,
qui permit to
any awdureprior tents Wt he Is alwrequ pursueat to the ro aidons of the
any
pursuant it the pro 7000) of the
(Ile a oed statement that he t r9 (commencing
Contractor's3.(the ardammandPicense LAW fdater9(mm).,th Bouch xection mptth0W)ofDivi.umd
he fSecti pt7MISby and
bn3ofthe thealle ed exemption. Any violation
the bsala for the alleged exemption. Any Wolatlon ofSectionno m by any
for a pemJbabje[atheappllcanttoadvll pevlty o! not nnre than('five
[pkyER DEVICES
gWA1hING POOL ELECTRIC
OV[LETSSWITCHESFIXTURFSapplicant
hundred dollen(SM.
❑I,as owner of the property, or my employees with wages es their wk
will do the work and the structure is not Intended or offered for sale (sec 7011, Business and Professions Code: The Contractors License Law
NEW RRSDFIJIIAL EL73CIR SQFT.
-compensatIon,
-`'
;FLOO�D
'�TYP C UCTION
�does
not apply tom ownsrd property who builds orlmprovea thereon and
does such work himself or through his own employees, provided that such improvements are not Intended oro(fered forsale. If, however, thebuilding mTOTAL:improvement bwMivithinomyearofcompldbgtheowner-buBderwUI have
ire burden of proving that he did not bund or Improve for purpose ofule.).
❑ L as owner of the property, am exclusively contnding with licensed
contconstructa to construct the project ec (S 7011, Business and Professions Code:
The Contractor's License Law don not apply to an owner ni property who
build, or Improvn thereon, and who contrast fm Such pcojects with a
og0((aa s)hmnwdpursuanttothe Contmdm'a License Law.
L� 1 am exempt under Sec B & P C for this nawn
a
RES. UNITSwho
QTY, PLUMBING PERMIT FEEE
APN
PERMIT ISSUANCE 0
ALTER DRAIN & VENT WATER (EM �D
FEE SUMMARY
BACK FLOW PROTFLT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
BBC= N
Owner Data
' FIXTURES. PER.. ' 1 QQ
SCHOOLTAX Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION
I ❑I hereby affirm that I have a mrtigcate of consent to self -Insure, ora
' cerBfnrate ofWorkera Compewtlonlruumnda or a certified copy thereof(Sec.
3800, lab Cd
GAS EA. SYS17EM-1 INCA OUTLETS
PARK FEE Y N_
RECEIPT N
Policy N
Co any
CAS EA. SYSTEM -OVER 4 (EA)
BUILDING DI VISION FEES
�Certlned copy is herebytthehed.
ertined copy V filed withh the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thb se Han need not be complded Bthe permit laforam hundred dollars
($100)mlexa)WATER
I certifythat In the performanceo(the work forwhich this pemdt Is Waed,
GREASE/INDUSTRL WASCE INTERCEPTOR
PLANCHECK FEE
PAIIJ�"� 1 G k
Date 2CC1 [ 1 t-
GREASE TRAP
SEWER -SANITARY -STORM EA HAFT
HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING06
I shall not employ any person in any manner w as to become subject to the
Workers Campen..u..La.c,f C.Ilfm.ha, Data
ApplicantNEW
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should baste subject to the Warkers Compensation provisions of the Labor
PAID
Date Re i t#
RESIDENTIAL PLMB. SQFT.
TOTAL:
jw ILDING 1
Code, you moat forthwith comply with such proWsions or this permit shall be
deemen! oked.
CONSTRUCTION LENDING AGENCY
Iherebyaf0rmthat there is a construction lending agency for the perform-
and of the work for which this permit is Issued (Sec. 3097, Civ. C.)
lenders Name
Lendeit 6
SEISMIC FEE
TOTAL: 7aO
ELECTRICFEE .30
PLUMBING FEE • co
Q TY. MECHANICAL PERMIT FEE
MECHANICAL FEE
I
Idrti.I,grehave
that
mply this wthallo"ndcualcm and te that the yoncilramieselntormdlm
kmrmct.lagrcetocomply withal! ctty and county ordlnanon and data laws
relaeng tobuildnng ronsractlm, and hereby authorize representatives,of this
cuyto enteruponthe above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep ha the Cu of Cupertino
a Ia ilitid,' Smarts ,band..pensee tt h.yinanyw.yy m=
a annst maty eorthe grant o t le It' m
V�
/ (J
Ig area ppllw /contra car Data
H 2ARDOUSMA RI ISCLOSURE
Will the applicant m future bund pant store or hand le hazardous
material.. defined by the Cupertino unicipal Code, Chapter9.l Z and the
Health and Safety Code Section 25532(a)T
Ely. No
Will the a ppliant mfuture building pant use equipment or d evils
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yes No
have read the hazardous outerials requirements under Chapter 6.95 of
PFdtMITLSSUANCE -Dd
FEES PAID:
Date Recei ted
ALTERORADDTOMECH. (JD
AIR HANDLING UNIT OOOCFM)
(TO 10,
SUBTOTAL'
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
EXHAUST HOOD (w/DUCT)
CONSTRUCTION TAX PAID:
Date Re ei tN
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
rMR�i
BOILER -COMP (311POR 100,000 BTU)
BOILER I P(OVER 100,000 BTU)
the Callfomla Health & Safety Code, Sections 25505, 25533 and 75534. 1
understand that if the building don not currently have a tenant, that it is my
NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Oaapancy.
fITM at ��t1LTIfQ
ISSUED BY:
Owner or authorised agent Date
TOTAL:
OFFICE COPY