22042 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
PERMIT NO.
Building padre.: fN - 22042 2OAn
weer. aces: ane: -
C_ [y pF_ C_kRey�,k Q� CITY OF CUPERTINO-BUILDING DIVISION / ❑ I^ �y A
Lic'" APPLICATION / PERMIT
COL[1SN Z BUILDINGELECn?ICAL-FLUMBINGMELHANICAL CATEGORY CONTROLp
Architect/Engineer.
MY ELECTRIC PERMIT IZEE BUILDING PERMIT INFO
Addmmo MICL V�'s�• . - PIRMITISSUANCE �p
Lm ENS EDCONT ACFOr pr DECLARATION eV 7�••
I hereby iffbm(hatl imsion3ofthe licensed uMnma dPm Chspmr9de,and MPIdANCFSRESIDF.NTIAL JOB
ETI0%
(ngwlthS1. 7000)afleff n3of(heguslnessand Professlonv Code,and my ` t
Ilcenae le In ml force and dfed. PANES
Limn C ss '8" UcM� '. 'u�o„SC.�SS bN 1�jUl
e• Contactor
ARCHITECTS DECLARATION 201-1000 AMPS -•
W0 z I understand my p Wu.hall W used.public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNSELECTRICAL' L E D
OWNGR-BNLDER DECLARATION
1`n] SPECIAL CIl2CNT/mIBG
7E' .7a ]herebyaffirmthallam exemLDER DE LARATIat.Licenae law forth.
pp 'fallowing mason.(Section 7031S,Business and Pro(essmae Code:Any city or E 1 i
O?k. ITURMETERORPOLEINST. y R
c rystmokh rrgsto it pexame,alsore uirestheaet,alter, provgdemoBsh,ormit to
g any asigneretatementehat he Is akcensed pursuant
to
the
provisionormich s
of to POWER DEVICES `
P O file a actors statement that het licensed pursuant to the pSection 7000) of the - / I
L61 Con3ofths Business
Law(Cluptons Cod)(corruorthatancing a with xamptthereofatil• SWIMMING POOL ELECTRIC v
��� emn basis for
the elle e d Procession.Any violation f exempt therefrom and DATION
Ci• the bast for the alleged exemption. Any violation of naltlon not m e,any OUTLETSSWITCIIF_SFIXTL ES -
app8ant for a perm(subject.the appOcanl to a dull penalty Moat more than
five 11,..o owndoler
of the property,
NEW RESIDENTIAL ELECTR
I,asownerll otproperty,orhe employeswith wages r fferesok - —�'�' STORIES TYPE CONSTRUCTION
7 acompensation,0K Business .d Preheat..
Code:
The Contractor.Wended o icense d for
La.
,qp do (Sec. ppy to alnower fpropety Cob:Theimprove,thamon Law
$ donnot applymanownerwpropertywho
nemple ImprovedhthtandwhodOCC.GROUP RFS.UNITS
EE lerimw carts aresuchwonot intended hraughhtowne.If,ho however,
thebuildisuch
Improvement are within
mrsale.theo vebuUder illhang or TOTAL:
improvement atwld within omycarofcomple(lon,theowner-buRderwillhave
the WI rden of proving that he did not build or improve for purpose of oak.). QTY. PLUMBING PERMIT FEE. FLOP ZONNE APN
OL ae net of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contndon to mrawci the project(See 7014,Bu.kess aM Professlov Cade:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wild.or Improves(herein, and who contracts for such p(o)ecis with a
cja(actw(s)licensed pursuant to the Contractor's Limnae Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
i i i em exempt under Sec. �B&P C for that reason
DRAINS FLOOR ROOF,ARIA,CO NO. SANITARY. Y N -
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION' - -
❑I hereby affirm a
that 1 have a rtiftmte of consent reFIX'NRES PER TRAPSCHOOL TA% Y N wit-lesu
,or RECEIPT
N
certificate of Workers'Comperaation Insurance or a certified copy themof(Sm.
38001Lb Cd CAS FA.SYSTEM-1 INCA OUTLETS PARK FEE. Y N
Policy# b/V Fi'Z wim e,Iq GAS EA.SYSTEM-OVER4(EA) - RECEIPT#
v ,BUILDING DIVISION FOES
ertlfied copy t herebydwithfurnished.tcity GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy t tiled with the city inspection divation.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE]RAP - PAID
Co be cont
COMPENSATION INSURANCE SEWEWSAMURY-STORM FA.20013'. Date - Recei t#
(TAleazctlon need no M completed If the SpermitURA t forone hundred dollen
($10(fiorless.) WATER IEt(EATW/VENT/ELECTR ENERGYFEE Y N
I namly that In the performance of the work for which We Permit b tailed, —
I shall not employ any Pa..in any manner m as to become subject to(he WATER SYSTEM/TRGTINC
Workers'Compenntlon Lawn of California.Data. PAID
O"Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date RCce1 t#
Z O NOTICE TO APPLICANT:If,a fter making tht Certificate of Exemption,you
should bemmcaubjrct to the Workers'Compensation provisions ofthe Labor TOTAL:
1 N Code,you mu.tmrthwithmmplywlthsuchprovistamorthtpermitshallbe UI
W > deemed revoked. FEE
CL C CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
I hereby affirm that there Is a construction landing agency for the perform, ELECTRIC FEE
z anceof the work for which tht permit t Issued(Sec.3097,Clv.Q TOTAL:
U 0 Lender'.Name - PLUMBING FEE
IL 1– Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE .
OW Icertlfylhatlhavemad(htappllmtlonandemtethattheabovelnformtion
IL Iscorrcd.I agree to comply with all city and county ordinances and mate laws PERMITISSUANCE FEE$PAID: '
>. N relating to building cotatrucilon,and hereby authorize repreentativesaftht
F- z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei t#
_ (We)agree to save,Indemnify an d keep harmers the the City of Cupertino
against liabilities,pdgmeres,cosatnd expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,OD0 CFM) SUBTOTAL:
agalnsts Id City mnarquence of the granting of this permit
-//b/9/ AIRHANDLINc UNIT(OVER 10,000cFM) CONSTRUCTION FAX
Signa rcof A p l n1/Co.tncior Dat. — BXHAUSTHoOD fiV/DUCT) ' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applIcantorfuture building occupant store or handle hzzardou. HEATING UNIT(TO 100,000 BTU) - DR1C Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
Health and SafetyCode Sedion 25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
I-1 Yes [�]No
111 the applicant or future building occupant use equipment or device. VENTILATION IAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air _
Quality Management D❑ttrtd, BOILER-COMP DI-N OR 1Il0,f%p BTU) -
4 Yee No
half.i.fthe.Ith& oily C.de,Sbdi. 25505t.under Chapter 6.95 of NOLLE&COMP(OV172700,OOB BTU)
the rawrdt Health&Safety Code;not currently
3550.5,ve at and,Shat. 1
undoretundihal if the notify the ing occupant
of the requir haveat which
that It tiny . NEW RESIDENTIAL MECH. SQ.FT.
rmorlo isuaim ofaC(he occupantollpancy. rementewhich must be met - '
prior to Issuance ofaCertlfkate of Occupancy.
Owner or authorized a gent Date
TOTAL: ISSUED BY:
OFFICE COPY