22985 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO,
Bu0ding AddressL, AU 22985
nen .ma 7 - one: -
ATPLI�HUN SUBMITTAL DA FE
CITY OF CUPERTINO-BUILDING DIVISION . /
c°mr eat/ Name Lk.N°: APPLICATION /PERMIT l `
BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CO
Arc ' Lk.No:
QTY ELECTRI P MIT E BUILDING PERMIT NFO
Address
PERMITISSUANCE
L FDNDECLARATION
afirmthat lamllcmunder provisions
raChspte
r9(commrno
Inwllhldfmn70101DlvlollIeBulssandPmtwlonsCmleand
Ilceonseisiatu ! defect.
Class8ank.p ✓ /Q
Date A1•PrLIANC ENML ��U7J�O
B D�PSCRI�'TfON
Contra or
ARCHITECTS DECLARATION 2WIODWAMPS
0 CZOC I understand my plans shaft be used as public records. O 1000 SJ.FT.FLOOR AREA f/SQ.FT.
k (/ Licensed Professional GNSELEC 3 77K Jl7 -2. 3�'
Q'Lz<r R OWNER-BUILDER DECLARATION WKIALCIR ISC L ID 7,012—
z
Iherebyafl.that l am exempt fromthe Contndor's License l�wfm the 3
pp following reason.(£edion 7WI5,Business and Professions Code:Any city or 70B T'�a ate
O2c. ve, TFMP.M RPOLE INSI.
G cdlowing eaequ rmaSedlon rrtdtrocomtvd,ofd Profeimpmons Code:
or
�5 anystmaturc priortoltsbawaace,aisorequirmthe applicant for such permit to POWFRDIXq
Bk b Rmns
Bk.signed statement that M ed punm
ut to the provisions of the
OwT� ContnctorL Lice.Lew(Chapter 9(commeacingwith Section 7000)ofDivi-
30,f don3ofthe Budn,sand Protamlom Code)orthcaathekeum therefmmand =PING POOL ELECTRIC VALUATION
~`�o.•]] the basis for the alleged exemption. Any violation of Section 70315 by any O ETSSWITCHESFl%'IVRES 22,5)
L 3 • ��
applint for a permit sub)edstheappllcant to a civil penalty of not name than ,/
$ (Iv61,asundowner of hepr. NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
GE11 I,as owner of the property,or my employe,with wage as there sok
< compensstloMwOldothe work and the drudurebnot intended or offered for10
O sale(See 7014,Buskas.ami Professlom Code:The CmAnson 's License Law
does not apply to an owner of property who builds or improv,thereon.and OCC.GROIIIs RES.UNITS
who do,such work himself orthrough his own employees,provided that such
Improvement are not Intended or offered for Sale.If,howevcp the bullding or TO
Improvemembsold within oneyearofcomplelion,the ownerbu iderwill have
tljLIturdan of proving that he did not build or Improve for purpose o/,leJ, QW. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with Ilmosed PERMIT ISSUANCE
contractors to construct the project(Sec 7014,Business and Profe,bns Code:
The Contractor's License Law does not apply to an owner of property who ALTIIt-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptojeds with a FEE SUMMARY
ec
cgBtradm(s)bomasd pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE El I am exempt under SB& re
P C for this ason
DRAINS FLOOR,ROOF A D. ARY Y N
Owner Dale RECQ['T N
WORIN/AN COMPENSATION DECLARATION FlXEURES iaul,T" Y_ N
❑I hereby affirm that I have a certificate of consent to self-insure,or a RECEI'f N
amiflate,of Workers'Comperadlonleaurmce m a,rtifled capythenof(Sec. GAS EA.5Y C A FEE Y N
Polk Tab C.) RECEIPT N
rollcyp GAS EA.SY OVER6(EA)
Com any BUILDING DIVISION FEES
Can",copy b hereby tussle city GREASE/ USTR ECK FEE
CertlRed copy b Ned with the city Inspection dlvlstm. r-s
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 7RA1' PAID 7
COMPENSATION INSURANCE SEVER-SANITARY-STORM EA 2rDFT Date Recei tic
(Thlssedlon need not be completed tithe permit b forone hundred dollars
. ($IOD)mr le,J WATER HEATER W,/VENT/ELECTR ENERGYFEE Y N
I certilythat lathe performenceotthe work forwhirh this permit is bsated,
I shall not employ any person In any manner so,to become subjed to the WATER SYSTEM/TREATING
Wmkera'Compeaaation Laws of California.Data
PAID
O Z Applicant NEW RESIDENTIAL PENCE. Date Recei tin
Z NOTICE TO APPLICANT:If,after making thisCedlfiate of Exemption,you
I" should become subject to the Workers'Compensation provisions ofthe Labor TOTAL: (I a
N
cc Code,you=at fort hwith comply with such provisions or this permit shall be O U �s1
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEEof
CL FS Ihembyaffirm t (5e
hat there b a controdion lending agency for the perform T ELECTRIC FEE Q
M Z ance mtthe worklor which this permit is Issued&c.3097,Civ.C.)
IJ O Lender's Name PLUMBING FEE (,
1L I— Lands/.Add ess QTY. MECHANICAL PERMIT FG MECHANICAL FEE
OW I cedifythatl have read thbapplicadonand statethattheabove Information
IL hard.I agmeto complywith all city and county ordinances and date laws PERMIT ISSUANCE PEES PAID:
miating to building construction,and hemby authorlu representativesof thk
(. N city to enter upon the above-mentioned property for inspection purpose. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify a"d keep harmless the City mf Cupertino Date Receipt#
V against liabilities,Judgements,costsand expenses which may in any wayamue, AIR HANDLING UNIT(TO 10,O)O CFM) SUBTOTAL:
against said City In exon a olthegmatingofthl -
AIRHANDLINGUNR(OVER 10,000CFM) CONSTRUCTION TAX
SI not pant/Cont%or
Data EXHAUST HOOD(W/DIJCA CONSTRUCTION TAX PAID:
HA2'ARDOUS MATE ALS DISCLOSURE
Will the appliantmNmrebulldln mpantstmo or handle haaardO°6 HEATING UNIT(TO 100,ODO BTU) Date Recel tic
mtterblasciefined by the Cupertino unicipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYee No
ill the appliantor turebuilding occapantum equipment ordevion VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air
Quality Ma ragement District? BOILER-COMP OHP OR 100,0(D BTU) n ^
4y, ❑❑No T A 1 V
havercadthehaadousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,DOO BTU)
the California Health&Safety Code,Sections 25505,25533 and 75536. 1
understand that lithe building don not currently have a tenant that it is my NEWRESIDENTMALMECH. SQ.FT ��� _ I T
responsibility to notify the occupant of the requirements which=at be mot 1 1992
prior to LW Ce (Icahn of Occupancy. v
n
Owner or authorImd agcntDate ISSUED BY-.
.10"
OFFICE COPY