22112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm en Identutration 7 PIERM17NO,
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CITY OF CUPERTINO-BUILDBJG DIVISION
cot oto wa Lte�NQ APPLICATION /PERMITI
BUfLDINGELECTRICALPLU.MBING-MECHANKAt. CATEGORY CONTROL A
ArdrltM/Fsglrcer.' Nu
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aa
PERMRISSUANCE
LI ENS DCO 'S DECLARATION �!y El
T hereby aHUmthetlam Bcrnsed underprovWaru dChapter9(®rvnm APPLIANCFSREEIDFMIAL JOB DESCRIPTION
In nee it infut7000)of DlvlNon3ofthe BudrceaandPro(eWauCade,and (/� ��
Ikons la lnW fo and d(ect__--9�9Sd PANELS
Lkunse Lb/ ,
Da �CaMactor
ARCH OECD C R TION 1-1000 A.V45
000 l undersand my plan atull be used n puble remda OVER 1000 AMPS SQ.FT.FLOOR ARFA f/SQ.FT.
Licensed Pm rob ul s in
owNH A L E D
SPECIALCIa eR-BUILDER DECLARATION
I..�� Iherebya(nnnthatlameoempt rromthe Comraaor'.LkamnetaWf«the
p9G t– followingreason. ires a p7015,Buelnm and Profmbns Code:Mycityir (-hMp_METG20RIDLE INST. M P U Tw E
�,Eg muntywMch requlrmapermNtomntrua,alter,improve,dertnWh,orrepalr —`/_'///
r� anystruaum pdmtolis Wusrce,slwrnrytrmthe appBcant(or such pern'at to f.P/ i
Oa fhe a dgned eatement that he b Ibensed Pursuant to the provbbm of the POWER DEVICES /
µ Contnnori Lkene Law(Chapter 9(mmnrnang with Section 7000)d Did- TE
a abn 3 ofthe Buelnm and PMesWro Code)ortM he Is exempt therefrom and SWIMMING POOL ELECTRIC
�Syp+ Sit•d the basis for the alleged exemption. Any violation d Section 70115 by any
appllrant fora pemat subjedsthe applleanttoaddlpevhY dnot rrontfun OUILETSSWIICRESFIXNRFS
five hundred dollars(SM.
F-1 1,n owner of the property,or my employee with wages as their sole NEW 14E9DFNf[AL Er Er1R SQ.FT. STORIES M ECONSTRUCDON
�7a compensation,will do the wnark.and The structure IT not LdendM or offered for
p sak(See.7D44,Business andPru/mlom Code:The Contcaaor.License Law
�$ does not apply to an owner of property who bullets orlmproveA thereon,and OCC.GROUT' RFS TENETS
whodoesuhworkhimselforthrough Msownemploye ,prwbMthatsuch
ImpmvemendaAm rad Mended earofcohowever,tMeru ingW TOTAL:
bnprovemem b add whit W orcyearolcompletbn,the owner-bullderwl111uve
t rdenofpruvingthathedd netbuudorlmprm.efwpdrpo.eer.ale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE AIN,
As owner of the Property,am essW.Nely contracting with Ilrenaed
mntndme to com,,a the projed(See 7004,Business and Profmbm Cade: PERMIT ISSUANCE o m1^t,
The Condrsaare Linens Law dao sot apply to an owner d property who ALTER-DRAIN k VEIAT-WATER(EN l
how.or Imp.thereon,and who for such P(ojem with a
ogTdra urW llansd pursuant to the CuetranoY.Lice.Lavv. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 Am nemp under Sec B k P c for this moon
OUTSI DF MES
DRAINSFI�OR ROOF,AREA,CONE). SANITARY Y— N_
Owner RECEIPT s
WORKMAN COMPENSATION DEE CLARATION p( S,PER TRAP SO100L T" Y_ N
❑I hereby Affirm that I have a certificate d consent to self-inarrc,or A RECEIPT l
mrtllicate o(Workm'CompenWlonlvunnm sea ortl(Ied copytherrof bac. GAS EA.SYSTEM-1 WC4OUTLETS PARK FEE Y N
IMLCY 3800,Tab C.)
c GAS EA.SYSITM-0VER 4(EA) DING DI g
Y BUILDING DIVISION xSION FT.FS
Certified copy b herebyth(WhM. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cert V ed ropy V filed with the city IvpMbn dlvW m.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRM PAID
COMPENSATION INSURANCE SEWEHSANITARYSTORM EA 20(77 Date. RCCCI t#
(Tins aeabn neM not he crxnplatM Rthe permit b frrorc hundred dollen
($t IoemlyTh WATECHFATERW/VENT/EIZTR ENERGYFEE Y N
Imolly thaththe p,.ni Any
thewok(ors To been.
subject
Iuanod.to the —
I shall not employ any Person f any manner at n to become subfea to the WATER SYS14f/TREATING
O A pllran CompevAtbn Lawsd Gllfonla.Dat< PAID
PP NETVRESIDENTIALPLMB. SQFT. Date Retnl t#
_Z p NOTICE ETO APPLICANT.Itsifter maddingCoope Certlp o/E ofthe you
shmld become subjct m the Worken'Compevatbn prvvi.bv ofthe Labor TOTAL:
LU N (eeondi umlood. with comply with each proWbv orthb pemat dullhe G .,
� > deemed revoked. '
W CONSTRICTION L040ING AGENCY SEI IC FEE
d IhembyafRrm that there h a covhualon lending agency for the pedorm ELECT-RIC FEE
� Z Ana ofthe work for which this penNtfe leaned bee 30Y7,CIv.CJ TOTAL: s�
U O Lender'.Name PLUMBING FEE a
LL F g. lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
QW lmn"atlMwmadthl.appllcadonaMd tethatthe abovebdommlon
IL 6mrmct.Iagrcetocomply with all city and county ordinances And state lawn PERMIT ISSUANCE FEES PAID:
} N relating to holding mretmalon,AM hereby authorize representative of thio
F Zs city to enter upon the abovcmentbvd property fee lepectbn purpose. ALTER OR ADD TO MECH.veDate Recei t#
V — (We)agree,to saw,indemnify an d keep harrrdm the City of Cupertino
".milllabWt ,jodgmenV,cateA xpensewhkhmaylnmywayamue AIR FIANDLING UNIT CEO 10,000 CFM) SUBTOTAL:
Xtrostaal yin e.cf graniWgd •pe IL
SAIR FIANDUNG UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
gnatu,t of Appilant/Contra — E)
to O3AU5T FLOOD(W/DUCE) CONSTRUCTION TAX PAID:
HAL4R DOUS MATERIALS DISCLOSURE
Will the.pp0nnt or future building omn Not stomor luMle havndwa HEATING UNIT(TO IOD,O)O BTU) Date Re[Ci l#
material aA defined by the Cupertino Municipal Cade,Chapter 9.1Z and the
Heahh and Safety Cader�-S�ection 25537(p)7 HEATING UNIT(OVER 100,000 BM TOTAL: ylo� U0
RYn I_I No
dithe.ppBcant orruutum Wilding«cupant use equlpmeet or devines VINIILATION FAN(SINGLE REED) ISSUANCE DATE
whlch emit havndoua air contAndrunta as defined by the Bay Ana Air
Quality Mavgement DW rla7 BOBFR-COMP Ol E'OR IOQIXq BTU)
171 YnNo
havemadthaharr rials requlmments under Chapter 6.95 of BOILER CVMP(OVER 100,0008111) y
the 00fomla l leahh 6 SafetyCade,Section 25505,25533 and 75534.1 A1/ q !'f!lll
understand m ro
that lithe building dot currently have a tenant,that It k my NEW RESIDENTIAL MEIN. SQ.FT. MAY R 1,3,:11
respovlbBRy to notify the acaparu of m
the qulmmust h
mee which must mot
Prior to bAut- a ofd CertlOcate of Occupanq.
Ownerorautharlu .Sent Date ISSUEDBY'
TOTAL:
OFFICE COPY
BETHEL LUTHERAN
AM/PM CLUB
GIRLS EXISTING RESTROOM
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IN App 0� ,I p
ACCrw
ORDANCE WITH THD _
nr OF
r. AND ORDINANCES
be
This set of plans and It d x
kept on the jSr
obnd pecol ar,.on C �Y
ST
Iewlu! to mryce any II times and it is un•
Without writte $es or afte - s
the building pa Dermiaslon from b
the >�mping°j t., City t Cu e .
SHALL NOT this plan end p ecill
A held to �oations
I of the violation rmit or to an
to hN��l4 Ardinance or
°n y Provisions
VE
14AY 4 " a
"LOG- INSPECTION pEp
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CUPptTj Q
BETHEL LUTHERAN
AM/PM CLUB
GIRLS PROPOSED RESTROOM
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BF.THEL LUTHERAN
AM/PM CLUB
BOYS EXISTING RESTROOM
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BETHE.L LUTHERAN
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