2860 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
2� yzs ��� 0�27 22860
worts '- ane:
a� A =A
i1ccap–Tv Z S�S /33 CITY OF CUPERTINO-BUILDING DIVISION /0 –//- q I
Contrmbor s Name: Lir.N•�.yy APPLICATION /PERMIT / /
SS I—E I� J BUILDING-MBC'IRICALPLIMBINGMFCHAMCAL CATEGORY CONTROLN
Arehilret/Engineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
IPERh1IT ISSUANCE2 1:1 1:1 L1LICENSED CONTRACTOR'S DECLARATION
I hereby aflrm that l am licensed under provisions of Chapter 9(commxec APPLIANCES-RESIDENTIAL JOB DESCRITMON
ingwith Senion 700-0.!DiAd.n3ofthe Budnessand ProfeaslonsCode,and my
Locr.Z:ht ora—Liand en. 1373 PANELS O !1 Lys/1
Date-147 �_Codrector " J
ARCHITECTS DECLARATION
201-1000 AMPS �� vv"
Q❑O 1 understand my puns shall ore used as public records. OVER 1000 AMI•$ SQ.FI'.FLOOR AREA $/SQ.Fr'.
iG (/ Licensed Pectic astc al SIGNS ELECTRICAL q I�
¢6�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC !'T<'��I ;I"y _•
(hercby a(llrtnthatlam esem (romthe ConlraRor's License Law(or the TT
�OF� following reason.(Setlion 70715,Bualnessind Professions Code:Anycityor TEMp,METERORI'OLE INST. ~` ° ` ��//� Y �.
FLIp county which requlecta permit tormented,alter,improve,demolish,orrepsir �-` tf 4�
5a any structure prior to its Issuance,also requires the applicant for such permit to yWgf4 DEVICES
�Ey
O file a actor's License
that W b licensed pursuant it the previsions 700D) of the /,
3�G
Contractor's usince Law rodesser9Cods)onring with xemptth000)of Dlvi- SWIMMING POOL ELECTRIC D
H OS dehoub;fo Buknm and Pro(eption. Any viothat lation f exempt therefrom any ;
' the bean for the allegedpermit
subjects
exemption. Any t tolatbn of Section net re he
app11candredaper dollars;
r'Rslheapp11cantloa civil penalty of net morcthan OUILETSSWITCHESFUO'URES --!
Ova I,as o ner of (Ar,. NEW RESIDFMIAL ELFCTR
tf �n I,as owner o!the prap=tty,or my employees with wage as thetr aoie e'U-pTSID,,[S Tl'PE CONSfItUCT10N
C < (Sec.7044,Business and randthestrotmrebnm Wended.ievessed(or
$�p ale(Sec.7044,Business and Pro(ealora Code:The ContraRofs Lirerae Law
�$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP IUNTIS
who doessuch work himself orthm ugh his own employees,provided that such
improvements arc not Intended oro/ferelf for sale.If,however,the building or TOTAL:
improvement Ls sold within oneyeamfcomplo
etim,the wner-bu0der will have
th�q4urden o/proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FIppD7ANE
APN
U I,as owner of the property,am exclusively contracting with beemea PERMIT ISSUANCE
contractors to mmtmd the project(Sec.7044,Business and Prolesomes Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN
Wilds or Improves thereon, and who contract for such p0ojects with a &VENT-
WATER(EA)
coMactor(s)licensed pursuant to the Contractor'sLicense Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec. B&P C for this reason
Owner DateDRAINS FLOOR ROOK AREA,GOND. SANITARY
RFCEB'IN
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a cortificate of consent to pythsure,ora FIXTURES I'FR TRAP SCIBCK)L TAX Y N
certificate of W.rkeme'CompematlonIwuranre cearertltied copythetmf(Sec, RECEIPT— NM
Polis Isis C.) GAS EA.SYSTEM-1 INC.40UTLETS PARK FEE Y N
Policy p RECEIPT p
Com Cany GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
ertified ropy is hereby te cCREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
CcrtlOed ropy b(Iles withh the
e city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ,
COMPENSATION INSURANCE
RFla.ectbn need nu,,completed lithe pemdt bice me hundred dollars SEWER-SANITARY-STORM EA.2D)FT. Date RCCCI t#
($1I nr lea.) WATER HFATERW/VENT/M TR ENERGY FEE Y N
I unify that,,the performance olthe week for which tis permit is blued,
I.b.11 not employ any person in any manner so o bject to the
O
Works.'
soul. ova of CaAfumii prte'i6 WATER SYSIF7.1/I'AEATING PAID
—
z
��E'qt�
Z � NOTICE TIfe,sub)I-LeANttothe,aNer es'Compensation Certnicateof Ex,ofthe ,you NEW RESIDENTIAL PCMB. SQFT. Data Recei f#
F Code, Wcomr' forth tmuco Workeit sprovbiomrmit s Labor TOTAL:
WN Coda you must forthwith comply with such provisions.roc's permit shall be
> dremea revoked. BUILDING FEE '—
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE �0
I hereby alarm that there b a roestrunion lending agency for the perform-
] 0 ance of the work for which this permit b L.eued(Sec.3097,Civ.C3 TOTAL: ELECTRIC FEE
(� Lender'.Name
LL t= Lendr'r'.Arid... QIY. MECHANICAL PERMIT FEE PLUMBING FEE
O w Icon Ifythat l have read Ilbs-ppiccatlo...d date thattheabove information MECHANICALFEE
fl. Is correct.l agree to comply with all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
>. N mlacity to gt.buponge abuve ogand hereby
rtyor4epectirepresentatives.!this
F Z cityWenter
ee to save,
indemnify aned property forinspectionpurposes. ALTIXORADD TO MECH.
— (We)agree to save indemnify an d keep commies the City of Cupertino Date Receipt#
aganet liabilities,judgments,mks and expenses which may In any way accrue AIR HA NDLING UNIT(To 10,000 CFM) SUBTOTAL• /(>
against said City in c...equenre of the granting of this permit.
AIR HANDLING UNIT(OVER 10,IXIOCFM) ZCONSTRUC-nONTAX
Signature.!Applicant/Comramor Date EXHAUS'HOODIW/DUCT) TION TAX PAID:HAZARDOUS MATERIALS DISCLOSURE
Wiilthea ppliceel orfuture building ocmpam store or handle haramous HEATING UNTT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Recel t#
Health Safety Code,Section 25532,,)7 HEATING UNIT(OVER 100,000 SM TOTAL•
Will the applicant or❑future building occupant use equipments devices VENTILATION FAN(SINGLERESID) ISSUANCE DATE
which emit havardou.air omtamimnts a.defined by the Bay Area Air
Qu Illy Management Datrin7 BORER-COMP pFNDR l00,IXp BTU) .
4Yea ❑❑Na
haveread lealth&Safety ode,teriLe reons 25505,25511 and
Chapter G95 of BORER-COMP(OVER 1W,OpO BTU)
the Gllfornl.Health&Safety Code,$encore 75505,25533 and 25534. I
understand that if the building does not currently have s must tenant thatitbmy NEW RESIDENTIAL MECH. SQ Fr O� q 1 r �yf��
responsibility to notify the occupant of the requilements which be mat .7
pnort uanceglaCcrfiflcate of Ocrupanry,
Owner or aulhorlaca agent pate Q
TOTAL:
ISSUE
OFFICE COPY
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CITY OF CUPERTINO
INSPECTION DIVISION
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