22930 APPLICANT TO FILL IN INFORMATION WITHIN R
ED LINES — USE BALL POINT PEN ONLY
Building Procter Identification PERMIT NO.
j BuildingAddeme 22930 ,
1077;'t u P�
cane arae: "nage!
APPA
t a r SLhm'd-�' a/fS 8'Q�9 CITY OF CUPERTINO-BUILDING DIVISION
lean mr's ams: , f, L .Ne: APPLICATION /PERMIT
/P S 3 I G BUILDING-ELECTRICALMUMBING-MFLHAMCAL CA GORY CON ROLX
A chitett/Engineer. LIB No:
� �'a" ELIiC'C13IC PERMIT ' � r;FEE4iz - .y�'BUILDING PERMIT;INFO"x,"
PO.
Q
Address: (.0. /jQx 0$ N.4 /Ea./ Qa}V/�/Q PERMIT ISSUANCE - ❑ - ❑. . .(fid - ❑
LICENSED CONTRACTOR'S DECLARATION IY�K
I hsrebyaffirm that l am licensed under provisions of Chapter 9(commec- APPLIANCESRESIDENML JOB DESCRIPTION
mgwith Setti-n7000)of Division3 otthe Businessand ProtesaionsCMe,and my
license is in(u0 force deflect 4361 PANF35 yl,/
Llunse Class G Lisp �__
Date Contncmr4y/�a
ARCHITECT'S DECLARATION OVERI0AMI'S
geq�a0ZO Iunderstand my pierce shall be used epublic recordw OVER 1000 AMIa5 SQ.FT.FLOOR AREA S/SQ.ET.
rgd J Licensed Professional SIGNS ELECITUCAL " ' � '\I
:5 5i OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC R
t^�Pa Iherebya(firm that]aro eaem)n(romthe Contratter'a Llmnse law forthe 1
oo pppO foil Ing re�ms.(SaHon 70315,Buaineuand Professions Cade:Any city or
'sN=G cmuntywhichmquire,apermittocomtma,almr,Improv,dennli,h,orrepair tea.MHTFRORPOLEINST. _. - ^j c
'janyatm=mpeortalfs4suame,a4orequbetheappBuntfor...A permit to POWER DEVICES DATE
'O c.V file a signed statement that he Is licensed pursuant to the provisions of the
J p In Contractor's Litems Law(Chapter 9(commencing with gcaMon 7000)of Divi. SWMWNG POOL ELECTRIC
Re basisofthe for
ealleed exemption. Any)violatiat on
of exempt themfrom and VALUATION
the Wa4fortherusted eectsthan. Myvlolacon-(Saha 7031's byno
any OUTLE.ISSWrICt¢4FDmmES
0 applicantforaspears($Sbjnts theappWanttoadWl penalty o(na momlMn
FG Ove 1, aownerof he W). NEW RESIDENTIAL FT TR SQXT.
I,a owner-(the Property,or my employee with wages as their w4 STORES TYPE CONSTRUCTION
Iz tcompere don,wOldotMworkandthemmmmre notint,Medaroffetedfor
i C 0 u4 C.7014 Business and PMenCods,iona Ce:The Contractors Lim.law
rte$ doe nmapplytoanawnerofpropertywho Wilds or improvethenon.and
E whodaesuchworkh(mselforth.gh Maownemployeea,providedthatmcA OCC.GROUP RES UNITS
improvemenrs are not Intended oroffersd(weak.If,however,the W Ildlag er TOTAL;
improvementissold within oneyearofcomple mtM owner-bW)derw have „� „(
t rden of provingthat he did Ambuild orimprove forpurpose ofsae.). 'Q'TY, y'ti. PLUMBING PERMIT W '�t;,+'?'a;FEE;S FLOOD ZONE ApN
Lf L as owner of the property,am exclusively contracting with licensed
Monomers ers to mrestruct the project(Sec 7044R
Sun^=• mi aProfessions;Cods: If PERMIT'ISSUANCE
The Cmursctors License Law dee,not apply to an owner of property who
Wllda or Improve thereon,thereon,and whoca.mo, for such plojMALTER-DRAIN&VENT-WATER(EA)
s with a
orte)Bmnsed pursuant to Ne ContnctoraLWnee Law. ;? ',,. FEE'iSUMMARYC, , b
I am exempt under Sec. B&P this m
C for thason }"
BACK FLOW PROTECT.DEVICE --__i,`S ... ..._..
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
OwnOUTSIDFFEFS
er Dam RECEIPT
Y
WORKMAN COMP ENSmgft of emeaR,ATION Fp(�gE;PER TRAP SCHOOLTAX Y_ N—
. QI hereby affirm that I have a urdflum of consent m o y-tnaum,or RECEirI X
mrtl0ute ofWorken Compematienlmurana maurtB4d copytheree((Esc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
P I Lab C.) RFLEPIX
Poi p
Ca env 1 CAS EA.SYSTEM-0OVER
e,lac copy4herebyfumishd. BUILDING DIVISION FEES
MCertified ropy is coed with the city wprction division. GREASE/INDUSIRI,WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXEMPTION FROM WORKERS' GREAETRAP PAID
COMPENSATION INSURANCEPAID
EA 20aFr.
Date Recel t#
Ror I.j n semi net h complRM Blhe pemNt blmone hundred dollen
(E7ro)orlesa.) WATER HEATER w/vFNT'/E.ECTR ENERGYFEE Y N
fanmemtmthe peemnioeofN nnerwutohthlspemdtb Weed,
I O'k-' employ any-neon In any manner so as to became Rrbjett to the WATER SYSTEM/TREATING
Worken'Compensatlon laws o(Gllfmm4.Date PAID
`7Z Applicant
Z
O NOTICETO APPLICANT.If,after nuking this CertBlcatecd F,. e,you NEW RESIDENTIAL PLMB. SQ,FT. Date .Recei t#
should become subject to the Workan'Compeuatmn provision,-(the Labor TOTAL:
SN C,:Iyourtwst forlhwithcomply with such provisions orth4 permit shall be BUILDING
41 > deemed revoked. -_
1 p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaf0ren that there 4 a constmcdoo lending agency forthe perform TO AL ELECTRIC FEE
� Z ance of the work for which this permit 44mtM(Sec.3D97,Cie.C.)
-) 2 Pander's Name - t r „I. PLUMBING FEE
1 F Lender's Address Qiif:e „Ik1ECIiANiCAL PERIv11Tvz:'`' =',=r<'FEE{
O l urdfythat I MvereadthosappBmtlonand statethattheabove Nm
foutlon MECHANICAL FEE
4ca ect]agree to complywith all city and countyordinance,and Rate laws PERMIT ISSUANCE FEES PAID:
N W relating to Wilding ronstmnlon,and hereby authorize reprexntative fthis
Z city to enter upon the above-ment...d property for Wpeckm purposes. ALTTRORADDTOMECH. Date Reeei t#
_ (We)agree W save,IndemNly an d keep harmless the City of Cupertino
agaWtllabigde,jrdgmenb, As and expenses which may In any wayacwe AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL:
a imif'f In roc a
of
gra g of thea permit
�" / AIR HANDLING UNIT(OVER IQUDDCFM) CONSTRUCTION TAX
Slgn.na Apphu / -.tractor Date EXHAUST HOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS the
LB DISCIASURE
d1theapplleintufuturebudding occupant store or handle hazardous HEATING UNIT CIO 100,000 BTO Date Recei t#
material as defined by the Cupertino Murdcipal CMG Chapter 9.12,and the
Hcakb and Safety Cad a Section 255I (a), HEATING UNIT(OVER 100,000 BTU) IOTA O
7 Ye No Td
Will the applicant or future building occupant use equipment or or devices VENTILATION FAN(SINGLE RESID) 065
which which emit hasardeus air motaminanbas defined by the Bay Area Air
Y' iNrE
Q•r Iity Management District? BOILER-COMP(3M'OR 100,000 BTU)
4 Yes g No
have read the hazy mus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) NOV �(3(��
the California liealth&Safety Cod,Sectlom 2550.5,25ST3 and 755]1.l ''��11 5511
understand that if the building does not cvrmntly,have a tenant,that it is my NEWRISIDENTIALMECH. SQ.FT. ^1Ty
rmpomkbilityto nalfythe occepant of the mquimmenla which must be met L�f11 car {,UI'Ci'(I�IYU
prior to issuance u(a Ceni(iute olOttupanry. iI INU
O,vnur or awhmriud,gem Dale ISSUED ItYe
TOTAL:
OFFICE COPY