22786 APPLICANT TO FILL IN INFORMATION WIT.IJIN RED LINES - USE BALL POINT PEN NLYr
Building/Proles Identification I
Buildingg2 rous:66 Z iA .l J `ca.1 002
G a- L27 86
L � 1
wne� ams: I, one: SUBMITTAL. q —23 7.(a CITY OF CUPERTINO-BUILDING DIVISION G
Conmactn'a Na •. Lk.No:
APPLICATLQN !SERMIT / 2
ar/E l/�L! C'oKt7��cr, jY i BNLDINGELECTRIGLPL MBINGMECFiAMCAl CATEGORY CONTROLM
lie Architect/Engineer. Lk.No:
QQ _ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addren:p /C / � C ae, PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION LS
I hereby affirm that l son licensed under provisions of Chapter9(commen APPLIANCESRESIDENTIAL ]OB DESCRIPTION
IngwLiconithSediClasson7000)of DWbion3ofthe BuNnessand ProfessionsCode,and my
license b In full f end effLic,ect. r _ PANELS �—
' Date Contractor
ARCHITECT'S CLARA ON 701-]000 AMPS
q�a0�u2 Iundentandmyplansshail used as public remade OVERT SQ.FT.FLOOR AREA /�S/SQ.FT.
}e Z�j Licensed ProfessionalLECTRICA ( J y h'
< OWNEReBUILDER DECLARATION LILCIRCUIT/ 3 I V OO//
Z', K Thereby afflrt.&hemm3l,5,B .I...xempt from Contra.LicenceAydty.rlAwforthe (�
following reason.iresa p 7Bt15,Business and ProfenkN Cade:My dry it
F � TEMP.METLit ORPO INS(.
countywhich cture reior to apermktomsorequiresthnstruct,alter, apmvntfor such permit
to
qq Q anya signed
tate tents that he i,licensed
pursuant
to the loo inionsof e POWER DEVICES
V Ole a signed statement that he le Ik2nsod pursuant to the provisions of the Gg" 6
361. Contractor's Lice.law(Chapter 9(mmmencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC VALUATION
SOS sion3ofthe Busineaeand PmfemiomCode)orthatheisemmpttherefmmarut My
o the bafor the alleged exemption. Any violation of Section 7031.5 by anythan OUTLETSSWITCHFSXTU
FIRES
appRrant for a permit subjects the applicant to a civil penalty of not came
e
$ five hundred dollars($SOO). NSW RE9DSNIIAL ELFL:ITt SQ.FT. STORMS TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as then sole
mmpeneslion,will dothe work.and the structure is not Intended or offered for
O eak(S..70K Busbuasand Prefeaskma Code:The Contractors License law
fie$ does not apply to an owner of property who builds or improves thenen,and - OCC GROUP RFS UMTS
EEEEEE who dean such work himself orthrough Msown employees,provided that such
Improvements are not Intended oroffered for sale.If,however,the building or TOTAV
improvement Issold withinoneyearofmmpldiomtheowner-budderwDI have
ft-turden of proving that he did not build or improve for purpose ofeele.). QTY, PLUMBING PERMIT FEE
L]L as owner of the property,am exclusively contracting with licensed ( PERMIT ISSUANCE FLOOD ZONE APN
contactor to to construct the project(Sec.7014,Business and Professions Code: .
The Contractor's License law don na apply to an owner M property who ALTER-DRAIN&VENT-WATER[FA)
builds or Improve thereon,and who contract for such p(ojects with a FEE SUMMARY
�gWlactor(s)Bernard pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICELJ I am exempt under Sec. B k P C for this reason Q[Treinp FEES
• Owner Data DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y_ N
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURESPERTRAP �� SCIdOOLTAX Y N
I hereby affirm that I have a certificate of consent to self4murs,or RECEBT Y
coIcateofWorkeri Compsns3800,Lab Qyaitaa�n lnspuranmma certltedoopythemoicae. GAS EA SYSTEM-1 INC.40I17LEI5 PABX FEE Y_ N_
RECEIPT p
Comacv t CAS 4 ) BUILDING DIVISION FEES
Cc
copy is hereby furnished. CR R PLANCHECK FT.E
fCl
Certified!CERTICATTled OF D(I IMHOity N FROM
division. � 3Cj3
Ya' CERTIFl OMPE SATIO I N FROM WORK[RS' G PAID Z
COMPENSATION INSURANCE gElVEIF� Y-SIO Date �- Reoel t / 9
(Thio section need not be completed](the permit V Ionone hundred dollen
(S100)ml..) WATER HEATER W/VFxvELEc RIENERGYFEE Y 7
I certify that In the performance of thework furwhich this permit is hued,
I shall not employ any person In any runner so as to become subject to the WATER SYSTEM/TREA77KG
Workers'Compeneation Owsef CslifornhA
. Date PAID
O Z - Applicant
NEW RESIDENTIAL PLMB._SQ.FT. Date ReL'el
Z O NOlicant APPLICANT.If, m
,ager making this Certificate of Exemption,you
should become subject to the Workers'Compensettlon provisions of the Labor TOTAL: 14,5q
CC N Code,you=at forthwith comply with such provisions orthb permit shall be
ILI > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL f] ]herebyaffirm that then lsaconstmctlon lending agency for the perform TO ELECTRICFEE �^^
0 ounce o(the work forwhichthb permit le issued(Sec.3097,CIv.C.) I —�
lander.Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FE
OW 1c rtifythatl have reacithlsappialionand setethatlheabove information
(i ecornrY.lcgreetocomplywlthandtyandcountyoNlnances and stal.laws PERMIT ISSUANCE ��� FEES PAID:
W relating tobullding construction,and hereby authorlu repmm�tativn o(lhb
f" city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? 0 agree to save,Indemnify and keep harmless the City of Cupertlnu Date RCOeI t#
L.I again tiabihtles,judgment,m sandexpenseswhlchmaylnanywayamue AIR HANDLING UNIT frOIO,ODOCFM) SUBTOTAL:
.get tsaidG�riot el,mnceo(thegra Ing of thlapemilt AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
ns reef Ap2plicent/ContrDatta EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOatt MATERIALSDISCLOSURE
Will the applicant orfuture building occupant store or handle havrdous HEATING UNIT(TO 100,000 BM Date Rmci t#
material as defined by the Cupertino MuNctpaI Code,Chapter 9.1 Z,and the
Health and Safety Code Section 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL.
E Yn u No
IIIlheappRant or turebullding ocevpantuu equipment ordevkrs VENTILA710N FAN 67NGLE RESID) ISSUANCE DATE
which emit havardous air contaminants as defined by the Bay Area Air Iqq
. Ilty Management District? BOILER-COMP OHP OR 100,000 BTI!) M I D
IYYes (�'''II No
(have ad the hale us materials requirements under Chapter 5.95 of BOILER-COMP(OVER 100,000 BTI]) NOV 12 n
the Gllfeembe Health A Safety Code,Sections 25505,75533 and 75534.1 �(Ts7
that if the building does not currently have a tenant,that It fs my NEW RESIDENTIAL MECH. SQ�. 99Ibllity to nalfy the occupant of the requirements which must be ret C�iP!nderstand
ior to' saner aCedificam'IOcmpa �7 V UFF�CiJPLH�I�INU
er or aulheJd'd ent� �'` Date ISSUED 81'�Jl) w`—
IOTA �
OFFICE COPY
ADDITIONAL PERMIT FEES -
.t}. : rAJI LDI KIS PROJECT IDENTIFICATION VALnnON-
BUILDING"
DOPE ( Ifkip
--
NAM
En3 + .
[/�,(—�I—�•� `i �. FEE SUMMARY
l/1 \\ PHONE
OONTRAcrows - BUILDING '.
uO.NO. PLAN CHECK
_ OONTRACTORS 'FEE
' PHONE SEISMIC FEE
OTV. - -'ELECTRIC PERMIT - - FEE~ -
UTLETS-SWITCHES-RECEP ELECTRICLIGHTING FIXTURES
PLUMBING .
PPLIANCES-RESIDENTIAL '
PANELS MECHANICAL "
SIGNS
SIGNS TRANS. - ( X C .1-Y To A�(21
SPECIAL CIRCUIT.
EMP.METER OR POLE INS. - vewmrt VALIDATION
MOTORS - SEE FEE SCH. 1 , '
Q'
SERVICE CHANGE
' "
F TOTA
ISSUANCE DATE '
- w > OTV. - PLUMBING PERMIT'- FEE. BLDG. EL PLG.: MECH.
O_"p
=),z 'ALTER-DRAIN&VENT-WATER IEA.) L•
'V b BACK FLOW PROTECT.DEVICE T
ROOF,'AREA,COND. _ ' r
• ;O'w DRAWS-FLOOR,, t
} m FIXTURES-PER TRAP."
F Z- GAS:EA.SYSTEM-11NC.40UTLETS - ""����✓✓f
(� GAS-"EA.SYSTEM-OVER,4(EA.)
INDUSTRIAL WASTE INTER. A Gj
' LAWN SPRINKLERS-i INC'5 V.B.
: .
- LAWN SPRINKLERS-ORM 51EA.)
" SEWERSANITARYSTORM EA.2001t/ - `X'��""\L••
WATER HEATER WNENT
WATER SYSTEM.-
WATER TREATING EQUIP.
'i'... I - - '• ..
OTV. _ - MECHANICAL PERMIT-- .FEE
ALTER OR ADD TO MECH." - "P A ' D` '
- APPLIANCE -
AIR HANDLING UNIT(TO 1000C.F.M)
JAN 2 Q q 7992
AIR HANDUNGUJITIOVER 10AMOFM.) _
EXHAUST HOOD(WITH DUCT) ,
HEATING UNIT(TO 100,000 B.T.U.) - ClI Y V} CIfCi- _ -
HEATING UNIT(OVER 100,000B.T.U.) -.
ISI' VENTILATION FAN ISINGLE) -
:
BOILER-OO 13,H.P.or 100,000 B.T.U.) - -
I'e
- BOILER-COMP Ow1 mD.oaB BTu15EE FEE'SCH.
TOTAL.