22983APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'eat IdemUkation
PERMITNO.
Building Addreaa: -
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22983
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CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGFlECTRICALPLUMBINGMECHAMCAL
1
L+ `k
Lit. No
C Tshmo: e 17 5'5—
CATEGORY
CONTROL Y
Architect/Englumr. Lt. Na.'
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrego
til ❑
LJ
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l amgcensed underprovlsicesof Chapter9(commmc-
IngwllhSectitn7000)of Dlvislon3ofthe Rusluasand PmtenlonsC e,mamy
licenae Is In fun to. and effecE `
Lt. naevClpl,_�.�a_LIeY I��7_.5�e // _
Date 7/ Contranor /'LQ -n (�Ae�{itua�w
APPLIANCES -RESIDENTIAL
JOB DESCRB'HON
_N
a
PANELS
AMPS
ARCHITECTS DECLARATION20I-IOW
I understand my plans shall be used as public records
OVER 10011 AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNSELECTRICAL 1
Licensed Professional
p R 1
SPECIAL CIRCUIT/ .• —
TEMp,MEITR OR PO INS.
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
coufollowing reason.(SeNon 7�IS, Bueinro and l'rafrobne Code: Mycity or
ntywhichmquim.ape tromutract,alter,U pmve,demolbh,ornpalr
N
_ Y.a�
,{tai[
anystmu mpr rtolteisaua=a,aborequimtheappncenifmsuchpermitto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Cha pier 9(commenMg with Section 7000) of Divi-
sion3ofthe Ou.inm.a dPtd.1.nsCode)orthatheberamptthemfmmand
the basis for the alleged exemption. Any violation of Section 70315 by any
apphoant fare permit subjecta the applicant to a civil penalty of not mcmthan
POWER DEVICES - DAT
VALUATION
gWR.1h17NC POOL ELECTRIC
OUTLETSSWITCHES D(TURFS--
five hundred dollars (5500).
L as owner of the ro as theles ole
p petty,ormyemhare
NEW RESIDENTIAL ELEGTR SQFL
STORIES
TYPECONSTRUCTION
is not Intendedo
compensation, ,wnldotheworkansiona rode:
iofferedfor
dile (get. alnow and Profrolona Code: Th L La.d
or Improves
emon,verces
don notoessuch toanownerdpmpeky who Wildeorlmprwnted that and
apply to
whoovementsa orkeIntenodmofgh hlsowne. eprovldM that such
OCC.GROUP
RFS. UMTS
If,ho
improvements ithindnoyearfeeed/pleale.ILhavoer-, 111
TOTAL:
havedingor
Improvement IseoW within ooyearolcmnplotbn,tFeowner-W llderwlll have
deer
PLUMBING PERMIT FEE
OMkrden of proving that he did not bund or improve for purpose of sale.).
u I, as owner of the property, am exclusively ocrumaing with licensed
contnttontoconatruct the project(So.7066, Businroand Profeolons Code:
QTY.
PF.RMITLSUANCE
I
FLOODZONE
APN'
The Contractor's License Law dm not apply to an owner of property who_L
Wilds Or Improve themoM and who contracts for- such pro)" with s
licensed pursuant to the Contractor's License Law.
T, am exempt under See. B & P C for this reason
OTT,
ALTER -DRAIN &VENT WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES _
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N
RECEPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
[—]I hercW afflrm that I have a nkNcete of consent to self -Insure or a
certffioteo! Orken'Compenaalion Wurancemacekl(kd copy thereo((So:
31100, lab CJ
FvnURE_. PER TRAP �
5U11WLTA% Y_ N
REC�� N
GAS F.A.SYSTEM-1 MCA OUTLETS
PARK FEE Y N ,
PolityY
BEC=Y
—
GAS EA. SYSTEM -OVER 4 (EA)
Com nye'
BUILDING DIVISION FEES
�CedifiedcopybhercbyfumlahM.
Codified copy is filed with the city Inspection division.
GREASE/INDUSTRL WASTE INTQtCEPTOR
PLANCHECK FEE
GREASE TRAP
a CERTIFICATE OF EXEMPTION FROM WOR KERS'
PAID
COMPENSATION INSURANCE
(Thisaectlon need notbecompleted Rthe permit Isforonehundred dollars
SEWER -SANITARY -STORM EA 2110Ff
Date Recel t#
WATER HEATER lit/VENT/ET.ECTR
ENERGY FEE Y N
PAID
(fiW)oif
I ceyth t r lm.)N theperfornunce o(thework (orwnich thio permit is heed,
I shall ns employ any person In any manner m as to become subject to the
Wor4en'Compensation Laws of GWornls. Date
WATER SYSTEM/TREATING
Applicant
NEWRESEDENTIALPLMB. SQFr.
Date Recti [#
NOTICE TO APPLICANT: If, after making this Certificate Of Exemption, you
Amid become subject to the Workers' Compenaatlon provisions of the Labor
TOTAL:
BUILDING FEE
Code, you =9 forthwith comply with such provisions or this permit shall be
domed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby af(Irmthat there is a construction lending agency for the perform -T
ance of the work for which this permit Is Issued (Sec 3097, Clv. C.)
Undoes Name
].endo. Addreaa
I mklfythat I laveread thisappnationami statethatthe above inf xtroglon
V cornet. l agree to comply with all city and county ordinances and nate laws
aa�
ELECTRIC FEE
_r
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building mwtructlon, and hereby authorize representatives of this
citytoenterupontheabove-mentioned property for Inspection purposes.
(Wel agree to save, Indemnify an d keep harmless the City of Cupertino
against llabWtks, judgmenb, mtasand expenses which may In any way accrue
Date Recei t#
-
ALTER ORADDTOMECK
AIR HANDLING UNIT CFO I O,ODO CFM)
SUBTOTAL:
.8.1r1rutt and �city
'�I. mnaequ oaf the granti`g d this permit.
J Q ��w.a' it M1191
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
- "-` -"'
Slgnatum of Appncent/Contractor Date
EXHAUST HOOD(W/DUC'D
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATWG UNIT (TO 100,000 BTU)
Will the a pplla nt or future building occupant store or handle hazardous
material as dented by the Cupertino Municipal Code, Chapter 9.1 2, and the
f❑Vemi��CW�Non2S32(a)?
,
Date Recel [#
'
TOTAL. L
HEATING UNIT (OVER 100,000 BTW
VENTILATION FAN (SINGLE REBID)
ISSUANCEDATE,
Will the applicant or forum building occupant use equipmem or devices
which emit hazardous ab contaminants as den nes by the Bay Ama Air
Quality Management District?
Yesn No
pY�B
P A B
BOILER -COMP DEE' OR 100,M BTW
ROILER-COMP(OVER IW.OW BTU)
4
o ium 2Senbundeand apter 2554.1 of
haveadeealth& afeus ty ode Sodium
Code, Sed lons25505,ve a tr and 25534. I
the Californiatandt at Ift a building
that rill the orgdms ofnot herequirmnts which
that It met
respundeonsibility
mponslbllity to notify the smpanl d the requirements which must be semi
prior to issuance d a CediflateofOccupancy.CITY
®v
9tr. CLQ
UFCUPfFii
ISSUED BY. WP
NEWRESIDENTIAL MECH. SQFT
Owner or authorized agent Date -
TOTAL: I
OFFICE COPY
TA