22684 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro'ed identification - PERMIT NO.
Building Address: 2 2 6 8 4
ma:
neva APPLICATIONgUlImITTAL DAM
c-• - CITY OF CUPERTINO-BUILDING DIVISION -
C dor'Wame: t Lk.No: APPLICATION / PERMIT CATEGORY
NTROLN
BURRING-ELECTRICAL-PLUMBINGMECH LAICAL
AmhfieWEngleener. Lic.No: • BUILDING PERMIT INFO
Q ELECTRICPERMIT FEE _
Addr.. � PERMITISSUANCE
RATIO . � ❑ � ❑ ❑
LICENSED CONTRACTOR'S DECLA
I hereby affirm that l am llcrosed under provisions of Chapter9(commmc APPLIANCES-RESIDENTIAL 100 DESCRIPTION
Iixw1thalnlulfo�a)andviacx3 ofthe Buslneasand ProfesslonsCode,and
nae Clans Llcp
auoas3 PANELS
Date Contractor
UIP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000 AMPS
p7„ I understand my plans shall be used as public records. OVERIODDAMPS. SQ.FT.FLOOR AREA S/SQ.Fr.
E� Licensed Professional _ SIGNS ELECTRICAL � � '' -
O«<< OWNER-BUILDER DECLARATION� SPECIALCEKUIT/MLSC Q
r Ihereby affirm that l am exempt fromthe Contractor.Lt...liw far the iLZAO P Ufollowing reason.(:section 7031.5,Buslnem and Professions Code:Any city or TEMP,METER OR POLE INST.
F,SCounty which requires a permit to construct alter,Improve,demolish,or repairany strudure Prior to Its Issuance,also requlres the applicant for such permit to POWER DEVICES
PJ Rle a signed statement that he b licensed pursuant to the provisions of the �I
Q6 O 1+i Contradorb License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
f.30 elon3otthe Buslneaeandl'rde.bns Code)orthet he laexempt lherefromand -
�` the basin for the alleged exemption. Any violation of Section 7MI5 by any OVILETSSWITCHE9-HXTUR65 _
«
applicant fora permit subjectsthe applicant toa civil penalty of not morethan
five hundred dollars($500). _
M1,as owner of the property,or my employees with wages as their sale NEW RESIDENTIAL ELECTR SQFI: STORIES TYPE CONSTRUCTION
compemation,wi ldothe work,and thestrudure is not Intended or offered for
Osale(Se.7044,Businesaand Pro(esions Code:The Contractors License law
$ does rad apply to an owner of property who Wilds or improves therem,and OCC.GROUP RFS.UNITS
EE wh.d.eesuch work hlaie0 or through his own employees,provided that such _
improvements are not Intended oroffered for sale.If,howevegthe bulli ingor TOTAL:
improvement is sold within ons yearafcompldlon,the owner-Wilder will have .
HI9]xudenof proving that he did not Wild or lmpnow for purpose of aide.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN ,
LI L as owner of the property,am exclusively contrading with used PERMIT ISSUANCE
contractors to mmtmd the project(Sec.7044,Business and Protestors,Code:
The Contractor.License I..it.na apply to an owner of property who ALTER-DRAIN&VENT-WATER WA)
Wilds or Improv.themem,and who contracts for such pnojeda with a FEE SUMMARY
cgpjlaetor(e)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. ' B&P C for thin mason
Owner ____Dam DRAINS FLOOR,ROOF,AREA,COND. SANITARY- RECEIPT p
WORKMAN COMPENSATION DECLARATION FIX1URES-PER TRAP {OOL TAX Y_ N_
Ell hereby afflmt that I have a certificate of consent to self-Insure,or a - RECEI'f p
anti(l.te of Worken'Compensatlonleaurana ora certified copy thereof(Sec. GASA. -I K FEE INCAOUTLETS PARK Y_ N_
3B00.Iab C.) RECEIPT B
Policy I GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Com!-y—
CA
�Certlfled mpylahercby lumlehed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certlfled copy is filed with the city i.pectlon division.
CERTIFICATE OFEXEMPION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA 200FI ,,, Date Remi t#
(Thissedlon need not be completed lithe permit is foram hundred dollars
($1000orless.) WATER HEATER W/VENT/Fl Will ENERGYFEE Y_ N_
I certify that in the pedomunm of thework forwhich this permit is Issued,
1 shall not employ any person In any manner..to become subkd to the ATTR SYSTEM EATING
Workere'CompenaaHon Lawsof 611(omla.Date PAID '
C✓ Z Applicant NEW RESIDENTIALI'LMB. SQd.T. Date Reeel t#
Z NOTICE TO APPLICANT-.If,after making thin CertHlcats of Exemption,you
O should became mbjeet to the Workers'Compensation provbio..(the Labor TOTAL:
f� Code,you moot forthwith comply with such provisions orthis permit shall be BUILDING_ deemed revoked.
IL CONSTRUCTION LENDING AGENCY I
SEISMIC F
CL
O co
I Ihereby offirmthatthem isardtmdlonleadlegagenryfortheperform, ELECTRICEE
Z arm of the work for which this permit is Issued(Sec.3097,CIv.C.) TOTAL.
V O Lender's Name PLUMBING FEE
IL Linke#Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU IcenifythatlhavemadthbapplimtlonaM statelhattheaboveiafomuHm FEES PAID:
iscorred.I Zipee to complywith all city and county ordinances and gate laws PERMITI.SSUANCE
} relating to building commsdlon,and hereby authorize representatives of this
f. Z cfi%enter .the above-rrenlb47dp!'
rtyfm impedbn Purposes. ALTER OR ADD TO MECH. Date RLCCIPf#
_ (We)a to save,Inde ty Aawh he City y CupertNoegalnst 11 tieaalTtlgment sn winin anyAIRHANDLiNGUNIT(7010,000CFM) SUBTOTAL:
gaene ng aZersolt CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX PAID:
IS reof Appllca / mracior to IXHAUSTHOOD(W/DUCT)
HA DOUS MATERIALS DISCIOSUR
iii the applicant orfuture building occupant store or handle hazardous HFATING UNIT(TO 100,000 BTU) Date Recei t#
Mto I as dell ned by the Cupertlno Municipal Code;Chapter 9.1 2,and the
Health and Safety Cade Section 2S5..W? HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes No
WY heappliranto Lure building ampantuuequipmentordevices VENTILATION FAN C51NGLE IT-D) IS
SUANCE DATE
Mich emit hazardous air contamirants as defined by the Bay Area Air Yg Rarev.
C Eallity Mlansgement GlY. ades? BOILER-COMP DHP OR 100,000 BTU) PAM
No
• linctus mad the b.ar�ios maledals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) •+ � � �_ -
theGllornlaHealth&Safety Code,Sections 25505,25533 and 25534.1 Y 19�n
understandlhatiftheblldingdo.ndcurrentlyhaveatenant,thatltismy NEW RESIDENTIAL MECH. SQFP. `�'�r
r.ponsbWtyto of ify aCeheoate of dthe
pancy. rementswhich must be mel
' prior to Lasuanre daCertlflcate of Occvpanry. '
Owner or authorized agent - Date ISSUED
BY,.—TOTAL:
OFFICE COPY