22492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prate Identification - PERMIT NO.
Buildingress,J. - 22492
ner�� Vk.fL sfj%e U*: CITY OF CUPERTINO-BUILDING DIVISION
® Contraelm'eName: an,A Y9an _ Lic.Ne: APPLICATION / PERMIT
2. QAI a
Z/Acteer. LnDINLCMCA4PLMBING-MCHCAL CATORY CO
Lie. o 92-1
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q1Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ' PERMITISSUANCE - '❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm,thatano Boosted Chapter9de,anena APPLIANCESRESBJEN77AL, ; JOB DFSCRIr1'ION
ingwlth Section7000)anDiels(on3 o(the Businessandl'rofesalo e,and my
If cense la(n and ef(eR. n 'PANELS
License Q+ Lic
0 Contractor
ARCHITECTS DECLARATIO 211E-1WOAM4PS
q ]understand mypiatusleallbeusedaspubllerecordw, OVERIOOOAMPS SQ.Fr.FLOOR AREA
q��uuy 028
Licensed Professional - - SIGNSELECTRICAL -,
<<�ja OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
0"� owing rason.(hatlamexampt 1315,B(roBushe iness
Profdorbs Coe:Law fort he
'Z O.. following reason. Bustnessand Professions Code: h, city or
�Z t.� R y ty TEMP.METER OR POLE INST.
,a arystr ctu�ntywhire requlresapemdtro construct,es themprove,aemolhh,ormitto
fileanyaM1vcwre prior tostatement
t hat he L,algia sed pursuant t the provisions
of he POWER DEVICES
Co a added statement that het licensed pursuant it the provhiom of the
w Contractor's usinee Law(Chapter (cods)ort ng with Section 7000)af and SWIMMING POOL ELECTRIC VALU N
ivi-
HBO elon3o(the Businece end Profemloru Code)orthat hehexemptthercfromand 9,UQ
yyyy the bash for the alleged exemption. Any violation of Section 7031.5 by anyIG
OU LE9S5WITCHES-F7%TURFS
p applicant for a permit subjects the applicant to a dvil penalty of not more than �[
�G77 five hundred dollars(S500) NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑1,as owner of the property,or my employees with wages as their sole
compensation,willaothe work and thestruclure is not intended or offered for
sale(Sec.7044,Business and PrefecturesCode:The Cmdbadols Llcerue Law
does not apply to an owner of property who builds or improves thereon,and
who doeasuchworkhmoulf erthrough his own employees,provided that such OCC.GROUP RFS.UNITS
Impervemenh are not Intended oroffered lcrsale.If,however,thebulldlegor TOTAL: .
provementheold within mayearofcompletion,the owner-Wilderwillhave '
the burden of proving that he aid reat build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
F1 L as at of the property,am exdueively contracting with Ilcenaed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's Limrue Law does not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA) t
Wilds or Imparves.therece,and who contracts for such pSojects with a - - FEE SUMMARY
cpRjfactor(a)licensed pursuant to the Contractor's License Law.
-' LJ I am exempt under Sec. B A P C for this rescan - BACK FLOW PROTECT.DEVICEOUTSIDE FEES
/ DRAINS.FLOORROOF,A COND. SANITARY Y ' N_
Owner - Date .t BBC=X
LL WORKMAN COMPENSATIONDECLARATION
r-- 'SCHOOL TAX Y_ N_
❑E hereby affirm that I have o certificate of consent to opytnsure (Sa RECER'r N
certificate C.Workeri Comperuatlonlvnurance ora certified ropythereof(Sec. G PARK FEE Y N
3500,Lab C.I RECEIPTM
Poliryp _ GAS.EA.9*114AVER4 )
Co n' BUILDING DIVISION FEES
s aedifted copy h hereby th the cid. GREA�arai L PLANCHECK FEE
rti(led ropy h filed with the city inspection division. �p. / f
CERTIFICATE OF E%EMPTION FROM WORKERS' GREASETRAP _ PAID-2f�f 43� '36-
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(OFI. die Recei [#
(Thissedi m need not be completed lithe permit hforone hundred dollars
(9110)orless.) WATER FIERIER W/VENT/m cr.I.R ENERGY FEE Y - N
-
Icertifythat In the performance ofthework(or chthlepermlthissued,
I shall not employ any person In any mann a t ben ubfM to the WATER SYSTEM/TREATING PAID
Workar C nLaws of +Enrol . a '4
Z Applirant�._ NEW RESIDENTIAL PCMB. SQ}T. Date Recei t#
Z O NOTICE TO :HA alter making t Cert a e of Exemption,you
shouldbecurrusubject to the Worken'Co ewathm provi.1 ollhe Labor - TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be - BN
j deemed revoked. "
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
W
I hereby affirenthatthem is acerestroctlon lendingagency forthe perform- TOTAL: ELECTRIC FEENO
D Z ance of the work for which this permit is Wood(Sec.3097,Civ.C.)
02 Lender's Name PLUMBING FEE
F Lender'.Address MECHANICAL PERMIT FEE QTY:
LL MECHANICAL FEE
O W Imet.I agrect complhhapalcitandconand tethattlee yordiances aboveinformation
Q. hcoingt Isgreeto comtruct on,a and hereby
tyorerepreesana state laws PERMIT ISSUANCE FEES PAID:
} W rekting tobuilaing comtmctlon,and hereby au ereprnenhtivea ofthis
city to enterupon the above-mentioned ro to Inspection Purposes. ALTERORADDTOMECH.
~ z y(Wa)agree save,indemnify an d p'a bar m e Cityf pertino Date Receip# -
V against liabilities,judgments,costs an see Ich mayinanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOT L:
t sane c necq of nit of this pc�ramIB' CONSTRUCTION TAX
/ —14_ r/ AIR HANDLING UNIT(OVER 10,000 CFM)
ignetu Applicant/Contractor Date E%HAWTHOOD(W/DUCT) CONSTRUCTION TAX P ID: -
HAZARDOUS MATERIALS DISCLOSURE -
Illtheappliwntorfulure building occupant store or handle hazardous HEATINGUNITOO100,00(IBTU) I. Date' r Recdpt
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU), TOTAL,
M Yet NNO
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air conlamioants as defined by the Bay Area Air BOILER-COMP p}(P DR 100,000 BTU)
Yea ❑No
shave read the hazardous Ilty Management District?materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��1t.'
'
the Glifornia Health k Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT. + L�
responsibility to notify the occupant of the requirements which must be met [`p
prior to Issuance of a Certificate of Occupancy. t X � j(7O
Owner or authorized agent Date 4 _ s7a7
TOTAL:
OFFICE COPY