22944APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'ect Identification' -
BvBdog Address: a
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PEI"TN22-944
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ne ams: ane:APPMENTTORMBRI
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBINC-MECHAMCAL
ITAL DA FL
iredor'ewme: LL ryl�A� r Lk. No:
CATEGORY CONTROL
Archlte /Engineer. LIc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: C
❑ ❑ ® ❑
PERhUi155UANCE
LICENSED CONTRACTOR'SunderDECLARATION
I4thShereby
ion7DOO)of Dt licensed uederpruumdPi/Cssions Dde,m en
[I ..h in fon force afdeffeon3o(Ihe Buslne.and Pi. feail.neC.de,and
license bins force and c.0 AW zioja
License Claes Lk.N
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
'
/V� C
PANELS
Date Contactor
f•.leACT
ARCHITECTS DECLARATION
I understand my plan.ha114 used u public records.
Licensed Professional
l/
OVER M
AMPS
OVER 1000 AMPSn
SQ. FT. FLOOR AREA
''\, I N
f/SQ. FT.
SIGNSELECTRICAL
SPECIALCIRCUIT/MISC ' (�
OWNER -BUILDER DECLARATION
Ihereby affirm that Ln License Law fort he
0
� P
�p METEROR POLE INST. Q
ppfyER DEVICES DATE
7exemptfro ossa d Professions
=ntyfollowingrehrequmi.e7 tto Business Pmfembneemlehny tltyir
c.y.t whlchpe 1.1t. er dt.,.I..trust,atter,impmvgdemolhh, er ttr
any structurepriorsnitshat he Is also sed pursuant
floe a signed that he punuant the provisions of the
t the (orsuions of
V
/' /e/ /f /
a
-
SWIMMING POOL ELECTRIC '
icess. La t r9lic(cons It
Contractor's Lkeme Lw(Chapmr9(mmmentlng a ih Section Divi.
.tond
rthat therefrom and
VALUATION
the basis thea]aeand exemption. Mylation f Section by any
app licant for a e permit
sd jedsthea My violation of nMion not
applicant for a permit subjedaheapplcant to a tlWl penalty dnot more than
OITILETSSWITCHESSFTXTURES
'
five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR _SQ.FT.
STORIES
.TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
sale IF.. 7061, Evilest. and Profeol.. Code: The Contract.?. Lt.. Iaw
does not apply to an owner of property who builds or Improves thereon, and
who dom such work himself orlhrough Me own employees, provided that such
OCC.GROUP
RES. UNITS
Improver ien{s.. not Intended oroffided for.le. If, however, thebullding m
Improvement exuld within one yea r.fcompletlon, the owner-bullderwll have
TOTAL:
th9.i;urden of proving that he did not build or Improve for purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed
contractor; to construct the projod (Sm. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD LANE
APN,
PERMIT ISSUANCE ..^^
• Irr/
The Contractor. License Law don nee apply to an owner of Property who
Wilds or Improves thereon, and who contracts for such p(olerts with a
<gB(pc[am or(e)Iaxneed punuantmthe Contrectorb Lkeno Law.
LII exempt under See B 4 P C for this reason
ALTER -DRAIN kVENT-WATER (F.A)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEPTN
Owner Data
WORKMAN COMPENSATION DECLARATION
I hereby M. that 1 have • cedlficam of consent elf -Insure, or
❑ m s
certificate of Worker Compensation Insurance ora certified copy themu(Ckc.
3800, lab CJ
Policy It
FIXTURES PER TRAP 40.011,
40•
SCHOOLTAX Y_ N_
RECEI'1' N
GAS EA. SYSTEM -I INC4 OUTLETS
PARK FEE Y N
RECEIR N
GAS EA. SYSITM-OVER
Co�any �
BUILDING DIVISION FEES
Ned copy is hereby furnished.
t2t.difiedl copy is filed with the city impedium division.
GREASEANDL5I71, WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thissectlon need not be completed ifiM permit is forom hundred dollars
Date - Recti t#
SEWER-gAM.I.ARY-SIDRM EA MIIII.
wATsaHEATF]tw/vENr/F2ECTR
ENERGY FEE Y N
s1O)mles.a
I certifythat In the performance of the work forwhich this permit 1. Issued,
WATER SYSTEM/TREATING ) OV
I shall not employ any person In any manner so . to became tabled to thefT�
Workers'C.mpensati.n Lawsof California. Date
PAID
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you
NEW RIMDFN17AL PLMB. SQ.Fr.
Date Reee1 t#
TOTAL:
should become subject to the Worker' Compensation provisions of the Labor
Code, you =at fort hwith comply with such provisions or this permit shall be
vod.
deemed reke
D E
SEISMIC FEE
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the perform
ante of the work for which this permit is issued (Sec. 3097, Civ. C.)
Land.?. Name
Lenders Addre.
m
I dlfylhatl have read thisappllotionand statethatthe above information
adrned.?agree tocomplywlthallcltyand countyordmancesand pate laws
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
.OD
MECHANICAL FEE
FEES PAID:
relating tobulldmg mmtructl. ! ndhereby authorize representatives of this
dtytoenteruponthe above- tiomdp for Inspection purposes.
(We) agree to ve, Inde 1ty an phem the City of Cupertino
agalmtlisbWtle dgmen dexpe awhlch may In anywayacosue
ALTER ORADDTO MECH.
Date Recei t#
AIR HANDLING UMT(f0 I0,000CFM)
SUBTOTAL:
t
u In an of sting of i
ail HANDLING .NIT (OVER lB,000cFM)
CONSTRUCTION TAX
Sig.in loot/ ondanor Data
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
X.t IDimb MATE RIALS DISCLOSURE
Will applicant or tore buldmg occupant tore or handle hasardws
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Heahh and Safety Code Section 25537(a)7
rj Yee � No
HEATING UNIT (TO 100,000 BT1>)
Date Recti t#
HEATING UNIT (OVFR 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
I$$I rA wlic'I.tD*�'E
Will the applicant ce future building occupant use equipment or devices
which emit hamrd.us air contaminants as defined by the Bay Area Air
i" Fes:
BOILER -CAMP pi -3P OR 100,000 BTU)
Quality Ma mgemtnt District?
Va. ❑❑ No
reshaaard.us materials requirements under Chapter8.95 of
,
NOVIhavc
N -6 1991
BOILER-GpMP(DYER IOO,000 BTU)
the Cxllf.mia Health 4 Safety Cade, SMiom 25505, 75533 and 75534. I
NEW RESIDENTIAL MECH. - SQ.rT.
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the mequirem nts which most be met
'
CITY Ue IiUrCH11NU
prior to Issuanced a CedNcate of Occupancy.
ISSUEDBY:
Owner or authorised agent Date
TOTAL:
OFFICE COPY