22483APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
PEIMITNO.
Building Address:
3S h r6 s r� Pr,
22483
one.
A A A
Jt�tred �. Wuf�Z
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
contractor's Name: Lie. No:
her
BUILDING.ELECTRICALML BINGMECFIAMCALCATEGORY
CONTROL N
Archtmet/Engincen Loc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: eJsCe A ` V `PFR?ATISSUANCE
� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyatfirmthal l am licensed under provislonsofChapter9(commeno-
Ingwlth Section 7000)ot Divblon3ofthr' Bwiressand ProlesnlnnsCode, and my
liana Is In lvl faros and a feet.
APPLIANCESRFSIDENTIAL
JOB DESCRIPTION
PANES
Idmnsc Class LIc.a
Date Contractor
— UP TO 20DAbQS
201-1000A,MPS
ARCHITECTS DECLARATION
I understand my plansshall be used as public records.
OVER 1000 AMPS
eSQ.FC.F(MA= ' S/SQ.FT.
SIGNSELECTRICAL
Licensed Pmfessiovl
A L E V
OWNEReBUILDER DECLARATION
I hereby affirm that Iamcaemptfromthe DECLARATION
License Law for the
r
A (1 C
SPECIALCI(CUIT/MISC
TEMP METER OR POLE INST.TUN
LOWER DEVICES
following reason. forsa n7nitto Business and Proprove, Code: Any city or
a prove,demolish, orrepairmitto
anycoustywhkhprior tea permit toconstruct,afteI%es the
any structure t.m.meto lt that he so
to
floe a actor's statement (Chapter he 9 (cams pursuant to the pcov7000) of the
pursuant to the provisions
Contractor's3 fthusins lowrofess9(commor thatseclog with xemonherefomDivi-
sion 3 Professions Code) or that he b exempt therefrom and
'\p/'
�k�C
TE
SWIMMING
ba"' for the alleged
the bask for the alleged exemption. Any violation of Section no m by any
applicant permitsubjects the applicant toes dull penalty of fiat mnrcthan
OUTLETSSWlTCHESHXrURES
-
I q Q7 -o
NEW RESIDENTIAL ELFLIR SQ
flue hundred dolhn(9500).
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSIRUCHON
compensation, will do the work and the structure is not Intended or offered for
sate (Sec. 7041, Business and Professions Code The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
who does such work Mmselfor through his own employees, provided that such
OCG CROUP
RFS.tATT$
improvements am not Intended or offend for sale. If, however, the building or
Improvement vasold within one yearoteemplellon, the ewnenbuild erwlll have
TOTAL;
the rden of proving that he did not bulla or improve for purpose of sale.).
Lj 4 as owner of the Property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044 Business and Profexlonu Code:
QTy. PLUMBING PERMIT FEE
PERMITISSUANCE
FLOOD ZONE
APN
The Contractor's License Law does nes apply to an owner of property who
Wor improves theeon, and who contracts for such pWjeds with a
,,Btt_r,aContraction'. clor(s) licensed pursuant to the Contraor's License Law.
I__I I am exempt under Sec. B 6 P C for this reason
ALTER -DRAIN 4 VENT - WATER
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
PER MAP
SANITARY Y_ N—
RECEIPTN
Owner Data
WORKMAN COMPENSATION DECLARATION
that I have a of
❑I hereby affirmWorkers'
to 'elfcopy
SCHODL TAX Y— N_
Insure, or
ceniliabC.te of Workers'Compertsatlonlnsuranaoraanifled copy thereof Sec.
o Insurance
c a certified
]S W, Lb C.I
RECEIPT' N
GAS F.A. S'YSTIMI INC{ OUTLETS
PARK FEY Y N
CeN
RECEIPTN
GAS F.A.SYSTEM-OVER
C°o' any
BUILDING DI VISION IT CS
Certified copy is he d with t e city
Certified ropy V filed with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
nes he completed tithe permit Is (a air' hundred dollen
(T)or
GREASE/INDUS RL WASTE INTERCEPTOR
P CHECK FEE
Ip 2'+y�I l7Z�l� J , L Q�
Date Recoi tN I"TI ✓-
GREASE TRAP _
SEINER-SANUARYSTORM EA 200FT
tm.onneed
(9100)orlesJ -
for to
Manly emplhat oy bco eesmltlsdsued,
1 shall not empty any person In any runner n as to become subject to the
anyhe Pinson
Worken'Cmmpenutlon lova o/Callfomla. Data
WATER HEATER W/VENT/ELECTR
E ERGY FEE Y N —
PA D
WATER SYSTEM/,TREATING
NOTIAppliCE
NOTICE on APPLICANT: a afterrrakingrhesa2tI0olpro is Exemption, you
should become svbFd to the Warken' Compensation provisions of the Labor
deemed ..],ed. must .�hwith comply with such previsions or this permit shall be
Date Remi tk
NEW RESIDENTIAL PLMR. SQ.FT.
TOTAL:
ANG FEE Lb
-BUIL
SETSMI FEE .1130
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lenclugagecy forthe perform
ane of the work for which this permit is Issued (Sec. 309'1, Clv. C.)
TOTAL
ELECTR FEE
Ierelers Name
Lcndcr;Addmsa
I certify that I have mad this application and statethattheabovelnformation
QTY. MECHANICAL PERMIT FEE
PLUMBIN FEE
MECHANI FEE
FEES PAID:
ucorrect. Iagreeeo comply with ail dtyand county osdinanm and Yate laws
PERMIT ISSUANCE
relating to building construction, and hereby authorize reprexntaBvea of this
city to enter upon the abovamxntioned property for Inspection purposes.
(We) agree to nave, In Ity an d keep her dens the City of Cupertino
ALTERORADDTOMECH.
Date Receip[R
.gains labllitles,pdgmr ts, Ysand expenseswhlch may lnanywayaceme
uId City in cone sen eo h antic ofthispemNt.
Q
1
AIR HANDLING UNIT (f010,000 CFM)
UBTOTAL:
AIRHANDLINGUNH(OVERI0,W0CiM)
CONSTRUCTI TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTIO TAX PAID:
S e App fit/Contra r Dae
A2ARDOUSMATERI SDISCLOSURE
HEAHNGUMTTT0100,000BIM
W app nt or future building pant store or handle haeardous
materul as def by the Cupertino Municipal Code, Chapter 9.12, and the
I4alth and Safety Cade Section 25532(p)?
❑ Yes NN.
Date COil t0
-
HEATING UNIT (OVER 100,000 BTU)
TAI'
VENTILATION FAN (SINGLE RIESID)
ISSUANCE DATE
_
Will the applicant or future building occupant use equipment ordevices
which emit haardorn air contaminants as defined by the Bay Area Air
Q�LAity Management District?
BOMER-UDMP OH'OR I00,1XI0 BTU)
YesNo
have read thehua mmaterials requlremenls under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 2.555.33 and 255X. I
ftly
BOILER-COMP(OVER 100,00O BTU)
NEW R6IDFNIIAL hfECH. SQ.IT
undnosotstaMyto that if the ocd ingcupant
docs oft a requiyhave aments lerun6 that b is met
napotoiJaius to of a Certificate of of he requlremeniswhich must be met
prior to Janus no, ofa Cenifiatc olOavpanry.
AUG
ash &na
Owner or authorized agent Date
TOTAL:
ISSUED eYC�
OFFICE COPY