22498APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification- -
BuBdlnPwdllaees�L CQ, e o Dr, e- -�
PERMITNO.
22498
w r 1�ame: A one'p
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O-
CITY OF CUPERTINBUILDING DIVISION'
APPLICATION I PERMIT
LOAM
Al/
2— �(
Aitect/Engineer. - Lk. No:
.BUR,DING-ELECTRICAIPLUMBING-MECHAMCAL
CATEGORY
-
CONTROLX-
¢TY ELECTRIC PERMIT FEE ,
BUILDING PERMIT INFO
^
Address: P (,LN Qr�
, PERMITISSUANCE
❑ ❑ ❑ .
LICENSED CONTRACTOR'S DECLARATION
[hereby dftrmthat I amlicensed under pro isionsof Chapter9(commrnc
Sedion7000)of Divldon3efthe usineasand Pyr fesslonsCode,anamy
license is in �Id(ed. O. F"�
Lice la aw Lk. p - J
Date Cantnctort
CHITECP DECLARAT N
- APPLLANCESRESTDENTIAL
]OB DESCRIPTIONingwith
� O /
C� !� ,•
PANELS
20140DOAMPS
OVERI000AMPS
SQ.FT.FLOORARFA S/SQ.FT.
I understand my place shall be used as public records.
SIGNS ELECTRICAL
Licensed Professiorul -
OWNER -BOLDER DECLARATION
[wing af0rmthatIamexemptfrom the Contractor's License Law for the
SPECIAL CIRCUIT/MISC
E D 1
TEMP. METER OR POLE INST.
POWER DEVICES
following equines a permi1$Bueineas and Professions Code: Any city or
anyscounty which rlreiap amt a6utmd,al theapliantfmolbh, er ttr
any atrudure prior statement that he is lice sed pursuant t the lor inions of t e
that he (Chapter Ilcensed pursuant to the provisions f the
floe a actors License
Contractor. usin slaw ession (rom) orthag with xSection
tbn of he eed mptth re of Divi-
exempt thcrefromany
Codr)irlation
A („
� /1
\/I U T E
V
SWIMMING ]TOOL ELECTRIC ..
VALUATION
basis forexemption.
the blab for the alleged exemption. Any violation of Section not na by any
f
ndreda permit aubjcctahe applicant to a dull penalty of not moretvn
OUTLETSSWITCHESFLXTURES .
five hundred
,five hundred dollen ($500).
F1 1, as owner of the pmperty,'or my employees with wages as their sole
NEW RESIDENTIAL ELECTS SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not intended or offered for
sale IS.. 7064, Business and professions Code: The Contractors License Law
does net apply to an owner of property who builds or improves thereon, and
who doeasuch work himself.rthrough his own employees, provided that such
OCC GROUP
,
RES. UNITS
improvements are not intended oroffered forsale. If, however, thebu+ldlegor
i prowerce bsold witMnoneyearofcomplebn,theowner-bu0derwRl have
[tkg�urde= owing that he did not build or improve for purpose ofsele.).
F1 L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7064, Busmen and Pr (..Ions Code:
TOTAL:
PLUMBING PERMIT FEE
QTY,
PERMIT ISSUANCE
FLOOD ZONE
'
APN
The C°ntndors License Law don not apply to an owner of property who
builds or Improves thereon, and who matndct
s for such pleje. with a
ogp�Tador(s) Braved pursuant to the Contractor's License Law.
LJ l am exempt under Sec: B & P C for this reason
ALTER-DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECTDEVICE
.
-OUTSIDE FEES -
DRAINSFLOOR ROOF, AREA, COND.
FIXTURES- PER TRA['
SANITARY Y N
RECEIPT X
Owner - Date
WORKMAN COMPENSATION DECLARATION
ereby affirm that I have a certificate of consent to self -insure, ora'
rtIicate ofworkers Compensation Insurance or a certified copy thereof(Eec.
00, lab CJ
Polley p 1 t
SCHOOL 7A% Y_ N
RECEIPT N
GAS EA.SYSIFM-1 INC.40UTLErS
PARK FEE Y N
RECEIPT p
GAS EA.SYSTEM-OVER4(EA) .
Com `
BUILDING
FEEffCrtledcoybhereleyfuMshS
(—ajCehified copy b filed with the city inspection division.
GREASEANDUSIRL WASTE INTERCEPTOR-
-DI -VISION
,PLANCHECKFEE
GREASETRAP
CERTIFICATEOFIXEMPFION FROM WORKERS'
PAID
SEWER -SANITARY - EA 2WFT -
STORM
COMPENSATION INSURANCE
(rhiesection need net becompided lithe permit b(or one hundred dollars
Date Remi t#
wATFRHRATERw/vENT/ELECTR
ENERGY FEE Y N
PAID
($100)orlend, -
I certifythat in the performance of the work ferwhlch this permit is issued,
d,
shall not employ any person in any manner so as to become subject to the
Workers' Compensation lawsof California. Date
WATER SYSTEM/TREATING
ApplicaN077Cnt
NOTICETO MPLICANT: e, after making this Ctionpr a of ons. ion, you
should become subject to the Workers' Compensation provisions office Labor
Date Recei t#
NEW RESIDENTIAL PLMB. SQFr.
-
TOTAL:
Code, you most fMhwith comply with such provisions orthis pernotshall be
deemed revoked.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
HourbyafRrm that there b a construction lending agency forthe perform
sons of the work for which this perMt b owed (&c. 309], CE, C.)
Lender'. Name
Le.der.Address -
ludifythailvvereadthsapplkalonandsatethattheabove Information
Is correct. Iagree to comply with all city and county ordinances and nate laws
rela0ng to building censtmdi..,ml hereby.uthodu repreeentativea of Mb
TOTAL:
-
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
0
I'
PERMIT ISSUANCE ��[v
FEES PAID:
•
-
city to enter upon the abovcerty mentined propfor Inspection purposes,
' (We) agree to save, Indemnify an d keep harmless the City of Cupertino
against llabBiles, judgments,costs and experseawhich may In any way accrue
against said City it consequence of the granting of this permit.'
ALTER OR ADD TO MECH..
Receipt#
AIR HANDLING UNIT (To 10,000 CFM)
- SUBTOTAL:
'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the '
I ealth and SafetyIon 25532(.)7
m Yea o
Will the appItcanA futurINbuilding occupant use equipment or devices
which emit hazardous air contaMmnta a. defined by the Bay Area Air
HEATING UNIT(TO 103,000 BTU) . 0
Date RUCeI t#
HEATING UNIT (OVER 100,000 BTO
TOTAL:
VENTILATION FAN (SINGLE RESID)
-
- IS$U.�SEtBB
i/A�t�F�TE
BOILER-COMP(3FEa OR 100,000 BTU)
Quality Managx.m.Disttrd2
I haYes
have read thehterialereuiremenunder Cha er 6.95 of
azToueQ�o rwrequirements
1 0
'JUL
BOILER -COMP 100,00081U)
the California Health&Safety Code, Sections 75505,25533 and 75534]
understand that lithe building does not currently have a tenant, thatit is my
responsibilit o rally the occupant ofthe reqire
uments which must be met
7idCY�
y
E4M a�4'
NEWREMEEENTIALMECH. SQ.FT.
prior to ofa dlllaate of Occupancy , . ^'
-1
W
'/
VI
ISSUEDBY:
Owner Jr'Zihofftod agent Date
TOTAL:
V OFFICE COPY