22808 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building
ulldln Pm ea ldendficatlon PERMIT NO.
Building Addreaa//:' �1 (�-�d /� /�,/ a�Q n/ f/�jn( (��{
ore �lp G �Nd f� �J/ /7 ro/-��3A\ /�2• 22808
,�3 CITY OF CUPERTINO-BUILDING DIVISION /O.� r SQA
APPLICATION /PERMIT
C l -1
Lt.No:
BUILDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Arc tett/Engineer., •
a�#� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcsa: sy j,2 PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
]hereby affirm that lam licensed under provisions of Chapter9(commeic. APPLIANCES-RESIDENTIAL ]Oil DESCRU'TION
ingwith Se ion7000)of DiWWm3ofthe si sae dProf elonsCode,andmy
Iimnre is in Rforce and cites-_---'� PANELS 4 �-/ \'��•'G) V-� `r
Licen la Lice
Date Confractor
ARCHITECTS DECLARATION 201-1000AMPS
q�v mO Zp0 I understand my plans shall be used as public records OVER IOW AM% SQ.FT.FLOOR AREA $/SQ.Ff.
U Licensed Profc.s .l SIGNS ELECTRICAL 3t�
OWNER-BUILDER DECLARATION SPECIALCB2CUIT/MIST p
owing affirm...(mfion 7 31.5,B fromehe d Professions
License Law for the �I �/ U
ZO 2 F
following recon.(Rection 70'f1.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST. Ell L Vj Ill
PMcounlywhichrequre-aper ttomrmtrudidWr,Impmve,de=lWh,orrepalr
9P8 file any atmaned #dertoiment issuance,licensed rersuant to the
provisions
of,t a POWERDEVICES � � Q-./ {��1
Cosa signed statement that he la licensed pursuant it the pmWions of the v o vl
3 w Contractors License Law(Cluster 9(commencing with Seaton 7000)of Divi- SWIDIMING POOL ELECTRIC
nN sion3b( 1 -4
the Business and Professions Code)orthat hebexempltherefmmand LU
�' the basis for the alleged exemption. Any violation of Section 7031.5 by any
Q TN
applicant for a permit subjects the applicant to a civil penalty a not more than OUTLETS-SWITCHES-FIXTURES
five hundred dollars hepr. NEWRESIDENTIALELECTR SQ,FT,
❑e s owner of the property,or he employees with wages their sole CONSTRUCTION
compensation,Business and
rk Firnndthestrode:Th Contractornt intended or License
Law
sale(Sec.apply
to an ow and f property Code:The Contractees License Law
$$ whododoes applytoanownerorthmug losown who idsorme,improves theme,and
h OCC.CROUP
Imp=ssuchwenotIntendedoroughhisowale.It owevrthehthat irgor
Improvementsarena ince"dedorrofco forsak.If,eh neeg deer ilI have - TOTAL,
Improvement laeold withinoneyearafcompletion,theawner-bulWerwill have -
t"raen of proving that he didrmt build or improve for purpose oteak.). QTY, PLUMBINGPERMIT FEE pLOOD ZONE APIA
u L as owner of the property,am exclusively mntracting with licensed PERMIT ISSUANCE
comma.to construct the project(Sec 7044,Business and Profeseloro Code: '
The Cor aaoes License law does net apply to an owner of property who ALTER-DRAIN k VENT WATER(EN
builds or Improves thereon, and who contracts for such plojaas with a
acus(s)licensed pursuant In the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C (or this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
` Date RFCEBrr#
1
WORKMAN COMPENSATION DECLARATION - PER TRAP SCHOOLTAX Y N_
❑I hereby affirm that I have cafe of consent to selfdnsure,ora FIXTURES. RECEIPT 0
certificaterkers'CompersaHo Emun Wurantt oracertlfkd ropythereo!(Sec. GAS EA.SYSTEM-1 WC.d OUTLETS PARK FEE Y - N
38 W,Lab bC.)C.)
Policy It RECEIPT It
Com any GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
❑pCertmed copy is he d withfurnished.tcity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID.
RM
* COMPENSATION INSURANCE SEWERSANITARYSTORMEA2001rr. - Dale Recei t#
asecineed lon not be completed](the permit V forone hundred dollars
($10MorlessJ WATER HEATER W/VENT/RLFCTR ENERGY FEE Y N
Ittrtlfythat performanceW
the performance of thewerk forwhlch this permit is lamed,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
0 Z Applicant
Z Q NOTICE TO APPLICANT:If,after making this Certificate of&emptWn,you NEW RESIDENTIAL PLMB. SQ,Fr Date Remi t#
Fshould become aubpct to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you moat fMhwith mmpiy with such provisions or this permit shall be BUILDING deemed revoked.
W
p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mnstmctlon lending agency for the pedornry : ELECTRIC FEE
Z arre.fthrwmklm whkhthbp.rmti.Issued(Sec.3097,C1v.C.) TOTAL
V O 'Lenders Name - PLUMBING FEE
IL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdi(ythatlhavereadthL applirationand Aatethattheabo eelnformation l
1 bommot.l agreeto comply with all city and county ordinances and slate laws PERMIT ISSUANCE T FEE$PAID:
).,W relating to building construction,and hereby authorize representatives Of this
F Z city to enter upon the abovcmentioned property for Inspection purposes. ALTER OR ADD TO MECH, Date - Recel f#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,Pdgnents,mets and expenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag4mst eaI n enmofthegra ngofthispemmt.
_ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX' -
Sigreof Applicant/ ontraaor Dat INHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
IvHAZARDOUS MATERIALS DISCLOSURE
WEltheappli itor future building occupant store orh.odleh"rdoue
mHEATING UMT(T01 W,WO BTU) Date ROCei t#
aterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code , U25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes LJ I
Will the applicant MfffhuuusWre building occupant use equipment or devices VENTILATION FAN(SINGLE READ) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q 1lty Management District? BOILER-COMPOHPORIW,0MBTU)
I l Yea g No L�S�
theMeave read earth 9he a out modeiabmgW 25505, 5533urdarChapter.11 of BOILERCOMP(OVER]W,BW BTU) d� '
Health&Salety Code,Sections 7550.5,25533 and 25534.1 OCT _
understand that if the building does net currently have a tenant,that It is my NEW RESIDFI-MAL MECH. 4
SQ.FT. a
responsibility to rattly the occupant of the requirements which must be met
prier to Issuance of a Certificate ofOccupanry. C`f
Owner or authorlad agent Data • ISSUED BYp`G
TOTA t
OFFICE COPY .