22921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMITNO.
Building Addresa166 4d A4MFc5TEA O ZD. 22921
Phone A A
;09 l 1 CITY OF CUPERTINO-BUILDING DIVISION
r I
xo k c. APPLICATION 1 -s PERMIT �e) — —
'� •
ArcMtect/ BNLDINGdECMCAL PLUMBING-MECHAMCAL CATEGORY CO
NTROL#
En neer Lk.No:
gl
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: E PFRMIIiISSUANCE .� ❑ ❑ ❑
LICENSED CONTRACTOR'S pr DECLARATION
I hth Smros7000atlamscewedunderinessa dPreChapter9(mmmmc AITLIANCESRESIDENTIAL JOB DFSC lION
ingwlth5ection710)of Divifect. ofthe Businessand Pro(essioneCode,and my
LImmrsia for�nd effect. PANELS
License Cla �/CJ Lk.p
Date �onITIECr
7�rs nd CNITECP d C RATION OVER
10 AMPS , l
�q+070, ]understand my plans shall be used as public records. OVER IIO AMPS `,Q.FT.FLOOR AREA 5/SQ.FT.
M d O Ill...it Professional SIGNS ELECTRICAL
z
6 OWNEReBUILDER DECLARATIONI hereby a.Law for the SPECIALCIRCUIT/MISC
z62;�q owingrafB .(Sectm that[amexempHroessandm the rofessossCode:A Any
following reason.(Section 7 t t.Business and Professions,, Code:Any d p or
� t"'t�. countywhlchrequlresapermit tomwtmct,alter,bnprove,dertnRsh,orrepalr TEMP.METER OR POLE INST.
5 ,a any structure priorto its Issuance,Ilan requlrestheapplieanHorsuch permit to
Q a U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
sion3 ofthe Budlnesand Profeaslons Code)orthat he is eumpttherefromand VALUAEl TION
a El O S the basis for the alleged exemption. Any violation of Section 711.5 by any 9 OUTLE7SSWITCHESFIXCURES x
4'
applicant for a permit subjects the applicant to a dvii penalty.!not more than
1 $� five hundred dollars($500). NEW RESIDENTIAL ELECTR
I,as owwr of the property, SQ.FT. STORIES
p, ❑ p perry,or my employees with wages r their dole TYPE CONSTI2L'CT[ON
^Q, sale(Sec.744,wWdothe ess and work,and tom Code:The
ut Contended.lemsed for
Law
❑ sale does net apply to Business and f pr essions Code:The Contractors License law
c$$ whorl lappiytorkhi wlo(pmpertywho
nemplyi ,p idedtha,and OCC.GROUP
whodoementsaonotIntededorough Meowale.If owe providedildingch RFS.UMTS
Improvements arenot Intended mitered forsake IL however ihebul ill have TOTAL:
Improvement brovingsold lhln he did on Wild
of sahave a
t ben.!proving that he did rant build orlmprove for purpose of sale.).
QTY. PLUMBING PERMIT FEE FT,OpDpON.E APN
Lj I as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontradors to mwtrod ec
the project(S .7064,Business and Profe dans Code:
The Contmetorb License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improved thereon,and who mctp
ntraa for such tojectd with a
co,,RBlllIactor(s)licensed Pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec 0 4 P C for this reason
Owner Dau - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N '
WORKMAN COMPENSATION DECLARATION RECEIPT if
❑1 hereby affirm that I have a certificate of came,to aelf-Insum,or a FO(TIJRES PER TRAP SCIBOOL TAX Y N
certificate of Workeri Compensation Wurance ora certl(kd mpythereo((Sm. RECEIPT#
3800,Lab C.) GAS EA.SYSIFM-1 INC-4 OUTLETS PARK FEE Y N
Paltry# RECEIPT 0
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISIONFEES
Certified copy is hereby th the cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Certifled copy V(Pled with the city Inspection division.
I� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhissection need not becompletN ifthepermit b(oronehundred dollars SEWER-SANITARY-STORM EA."Fr. Date Recei t#
(El00)orfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that o the Perm,in n the work(ors to b this permit c Issued,
I shall not employ any person In any manner at w to become object to the
Worker%Compensation Laws of California.Date WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this CertRirete of Exemption,you NEW RESIDENTIAL PLMB. SQ,FT, Date Recei t#
should become Babied to the Workns
ers'Compeation provisns ioof the Labor TOTAL:
WF N Code,You=at forthwith comply with such provisions or this permit shall be
> deemed revoked. - BUIL I G FEE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there V a construction lending agency for the perform
7 O iouvmthework(orwhichtha permit it Issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
E
O Lender's NamePLUMBING FEE
LL L) LLender's AddreId QTY. MECHANICAL PERMIT FEE
O W Icertlfythatlhave read this appBcatlonand atatethanheabovelnInmates MECHANICAL FEE
--
9L is rorrect.I agreeto comply with all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID:
r N rclatingtabuildingrowtruction,ind herebyauthorue representatives ofthis
Z city to enter upon the above-mentianed property fur Wpecron purposes, ALIFRORADDTOMFGH.
— (We)agree to sav md kee
enify an p harmless the City of Cupertino Date Recei t#
WtlkbWtles P
go s,mdse erartin ofthl.may in any wayaccrue AIA]iANDLINC UNIT 10,000 CFM) SUBTOTAL'
tsald Ci In roe care. grantingofthis pe It.
3O.7/ AIR HANDLINGUNIT(OVER 10,00oCFM) CONSTRUCTION TAX
SlgnatureofA Brent/Cant dor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and the Date Recei t#
I❑Ywo
d Safety Cod Non 25532(a)? HEATING UNIT(OVER 11,01 BTU) TOTAL:
Wilitheapplicant mmre ildingoccvpantuseequlpmentordevices VENTILATION FAN(SINGLE RESID) ISBl1AyN ATC
which emit haurdous air contaminants as defined by the Bay Area Air 4✓
Qu 1ty ManagementD ctt BOILER-COMPOHPOR 100,000 BTU)
4 Yes No OCT 0
e'• 'havcrcadthe h oeus tyCodrialarequimrrcntsunder
isid2Chapter 6.95o( BOILER-COMP 1991
the California Health A Safety Code,Sections 25$05,75533 and 2$534. I
understand that if the building does not currently have a tenant,that It 4 my NEW RESIDENTIAL MECH. SQ.I7
responsibility to no By the occupant of the requimments which must be met "IIY Ur LUrCNIiNU
prior to Issuance of a Certificate of Occupancy. VL
Owneror authorlud agent Date ISSUED BY: A 1QaV
TOTAL:
OFFICE COPY