22099 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - 1- - - PERMITNO.
Building Address: - 1"1 n 0 n X99n
$' GG
ams: one: p
CITY OF CUPERTINO-BUILDING DIVISION '
G°^tad°'a Name: Lie,Nu: APPLICATION / PERMIT Vr o 1
BUILDINGELECTRICAL•PLUMBINGMECHAMCAL CATEGORY CONTROL#
Amhltea/Enginrer. Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address - - PfRMITISSIIANCE BILD(o. El_�j PLUME; MUCH
❑ O (Q'� ❑
LICENSE DCONTR under provisions
Yom`
with Se ion7OOfirm hat Divisi nsedheBusi sandamfessi ter9di,and c APPLIANCESRESIDENTAL JOB DFSCRETTON
It...1Sed1on7000)o(Dlefect. lheguaineasand Profeselon.Code,and my u
Iirenx Is In full once and effect. PANELS � �\
License 1-x _ Lk.# —7,R p(_- S �,`1
Date Conmeam— �L� ' UP TO 2DOANTS
ARCHITECPS DECLARATION 201-IODDAMPS
re$ I understand my platy shall be uaed aspublic records. OVER IOW AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
00
d0 Licensed Profess[°ml - ,�. SIGNSELECTRICAL -
.4 fllOWNL'R-BUILDER DECLARATION -
I herebyarm that l am exemplfrom the Contrador's License Lew fee the SPECIAL CIRCUIT/MISC
oo following mason.(Seaton 7031.5,Business and Professions Code:Any city or
,`Or.,ZE'u9 ceuntywhichmquimsapermktoconstmd,alter,impmve,de=llsh,orrepair TIIlNP.METER OR POLE INST.
any structure prior to its Issuance,also requi.a theapphcant forsueh permit to
Yd POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
��yyOw Contractor's License (ChapterLaw 9(commencin with Seaton 7000)of Divi- t"
G�SC
Q Ot SWIMMING POOL ELECTRIC don3of the Business and ProfessionsProfessionsCode)orthahe la exempt therefrom and VALUATION the basis for the alleged exemption. Any violation of Seaton 70312 by any OUTLETSSWITCHESFIXTURES
appllcant fora permit Subjects the applicant to a civil penalty of not more than
c.^�
five hundred dollars el SOOL I,as owner of the NEW RESIDENTIAL ELEGTR_SQ.FT. STORIES TYPE CONSTRUCTION
Q••�n ❑ property,or my employees with wages as their sole
compensadoe,wW dothe work and the struauro is not Intended or offered for
O -1.(So.7044,Budnessand Pmfemions Code:The Contndo?.Lt..Law
5$ does not apply to an owner of property who builds or imprwea thereon,and OCC.CROUP RFS.UNITSwho doessuch work hlmself°rthrough hisown employees,provided that such
Improvements arc not Intended oro(fered for sale.It,however,thebuilding or ,TOTAL:
Improvement hwld within°neyearafcompldkntheowner-bu0derw thave
tfcbaNenofprovingthat he did not build orimprove for purpose°fsele.). CITY. PLUMBING PERMIT 'FEE' FLOOD ZONE APN
ElL ae her of the property,am exclusively contracting with licensed PERMITRSSUANCC"
wntradon to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law dors not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such pW*u with a ALM-DRAIN&VENT-WATER(EA)
151 dor(s)licensed pursuant to the ContradoYa License Law. - FEE SUMMARY
Sm exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,CONE). SANITARY Y N
Owner Date c RECEIPT#
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
❑1 hereby orO that I have o l rtcone of consent d elf-insure,reor a RECEIPT N
rertl(Prete°f Worken'Compensatlonlnsuranre ora Certified copy there°((Sec. GAS EA.SYSTEM-1 INCAOUTLETS' PARRFEE Y_ N
3city
# ! Ll RECEIPT#
gmpa L�/ ��.�_:a f GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
°Y /
chilled copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy Is(fled with the city inspection division.
CEPT
CERTIFICATE OF EXEMION FROM WORKERS' GREASE TRAPPAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM LA.XIOFT. Date RCCCI IN
(Thbsedicn need not W complaed lithe pereo t Is forum hundred dollars
($100).,I..) WATER HRATERW/VENT/ELECTR ENERGY FEE Y N
certifythat in the pedomunreo(thework for which this permit[a Issued, /
I Kify •� —
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TRGTING -
Workers Compensation Laws of Callfornia.,Date PAID
O Z NOTICApplicaE
M[' NEW RESIDENTIAL PLMB, SQI.T. Date Recel tit
N
Z O NOTICE TO APPLICANT: after making this of Exemption,you.
H should becomesubectto the Wortn
e 'Compehuation proniohu ofthe Labor - ' TOTAL:
j Code,you moat forthwith comply with such provIslom orlhis permit shall be B
LU j dremed revoked. - '
EE
O. c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afOrm that there Is a construction lending agency for the perform � ELECTRIC FEE
V O
ZanocoofhowrckforwhlchthisperoutbblreIv
ued(S .3097,C .C.) TOTAL, / r PLUMBING FEE
LL F Lender•.Addreas QTY. " MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irerti(ythat l have mad thisappllnUab
on and statethattheoveinformatlon
UJ Isrorred.I agree to Comply with all city and county ordinances and state lawn PERMITISSUANCE FEES PAID: ,
relating to building construction,and hereby authorize representatives o(thls
-(- N city to enter upon the above�mentioned property for inspection purposes. ALTTRORADDTOMECH. -
? (We)agree m save,IndemNfy an d keep harmless the City of Cupertino Date Receipt#
V againstllabillli dgmema,costd expenses which may In anyway.arm AIR HANDLING UNIT CFO I0,0D0CFM) , SUBTOTAL'
again I tyinconsequenc 0111granting of this permit. Lb`
AIR HANDLING UNIT(OVER IO,WDCFI,) - CONSTRUCTION TAX
Ig azure of ppllcant °ntractor Date EKHAUSII IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant or future building occupant store or handle haeardous HEATING UNIT(T0100,000 BTU) - Date RL'cei tN
=mrial as defined by the Cu peril no Municipal Code,Chapter 9.17,and the .
(lealth❑Yesd Sally Code Seaton 255ffi(a)7 HGTINC UMT(OVER 100,00D BTU) - TOTAL:
Will theapplicant or(uiurc building occupant use equipment ordMms • VPNITLATION t'AN(SINGLE RFSID) - ISSUANCE DATE .
Which emit h..,d...air contaminant as defined by the Bay Area Air
Quality Management Dist dT BOILER-COMP OHPOR IW,IXq BTU) E�
4 Yr. No
have mad the haza ou.nutedA requimreenta uoder Cha pier 6.9S of BOILFR-COMP(OVER 100,000 BTU)
the California Health&Sofety Code,Sea3ons25SBS,75533 and 25534.1 JUN X G 1991
understand that if the building does not mrmntly have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ-FT "
nexpomiblllty to notify the occupant of the requirements which must be over
pEIgI 0P CUp9R tl0
(o�
014"j '41azzo-a-1
olo t°Lesuance da Cartl(I teo Occnpanry. i
U*pr
er orauthorized agent Date
TOTAL:" - ISSUED By
OFFICE COPY