22304 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'e I Identification 7 PERMIT NO.
Building Address:
zoo r I PNE, euP��lniv gyp., 95-014-- Z
2304
nera ams. one: - p
V� CITY OF CUPERTINO-BUILDING DIVISION /'
Conaaciars Nare: u.. « APPLICATION / PERMIT (0 I
ArchltM/Engles.. TEvem LIc.N BUILDINGELECTRICA4P-U BING-MECFIAMCAL CATEGORY CO
COI�ISI QY ELECTftiCPERMTT FEE BUILDING PERMITIN�FO�
Address: (,� FIRMITISSUANCE [:1 ❑ ❑
LICENSED CONTRACTOR' DECLARATION
I hereby affirm that lam licensed under provisions of Chapter 9(mmmmc APPLIANCES-RESIDENTIAL _ JOB DESCRIPTION
mewl is In
Full fore aid effeon3o(the Budnessand ProlesslonsCode,end my
license lSi ionfore)ofDi effect PANELS
Llmnse Clam LION
Date Comracmr UP TO200 ANTS
ARCHITECTS DECLARATION 201-1000 AMPS
Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FF.FLOOR AREA S/SQ.FT.
O �''1
c Licensed Professional SIGNS ELECTRICAL � 1 QQ
2 OWNER-BUILDER DECLARATION SI'ECIALCRCUIT/MISC - ��•OO
F, 7 Iherebyaf8reathat l amexempt fromthe Contractor'sLimns Lawforthe
following reason.(Section 70115,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
O cal cmntywhichrequlrnapemdtrometmd,Oteq Mpmvgdennllsh,orreper
Op."ri anystmcture priortoitabsuance,ala
.requamustheapplIcant for such permit to POWER DEVICESn f
V file a signed statement that he is licensed pursuant to the provisions of the ^
L`/O
u, Contractor's License law(Chapter 9(mmmencing with Section 7")of Divi- SWBdMING POOL ELECTRIC
30aC' slonlf ithe Business and Professioe Code)orthat he is exempttherefromand VALUATION
Q^I the W sis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHESFIXI"UI2E5 C=/
O applicant!...permitaubjedstheapplkanttoadAl,ultyofnm.m than
$ five hundred dollars($500. NEW RESIDENTIALELECTRSCI'FC.
❑I,as owner of the property,or my employees with wages as their sale STORIES 7YI'E CONSTRUCTION
�7a compensation,will dothe work,andthe structure b not Intended or offered for
5 ❑ sale(Sec.7DK B..Wntsand ProfessionsCode:The Contractors Uove Law,
$ does not apply loan owner of property who Wilds orlmprovesthereon,and OCC.GROUP RES UNITS
F$^ who doessuchwork himselforthrough hisown employees,provided thatsuch
improvements are not Intended..offered for sale.If,however,theb.ifi ing or TOTAL:
Improvement bsoldwithln oneyearofcompletion,the owner-bullderwlll have
Ila rd of proving that he did net bund or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the pmperty,am exclusively,contracting with Ilmnsed PERMIT ISSUANCE
contractors to mostruct the project(Sec.7044,Busimass and ProfesslomaCode:
The Contractors License Iaw don not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p ojects with a ALTER-DRAIN -WATER(EA)
09114-cmr(s)Bornsed pursuant to the Contractor's License Law. FEE SUMMARY
RACY FLOW PROTECT.DEVICE
UI am exempt under Sec. B k P C for thio reason
OUT41DE FEES
DRAINS FLOOR BODY,AREA,COND. SANITARY Y_ N_
Owner RECQFT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SC1400L TAX Y N
❑I hereby affirm that 1 have a certificate of consent to sect-Insure,ora RECEIT T M
certificate of Wcrkera Compereatlon Laurance or a certlfkd copy thereof(See. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT M
�kY^ GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FE ES
Y
mined ropy v hereby famished. - PLANC14ECK FEE z�a'
Certified mpy,is filed with the city inspection division. GRE45E TRAP RRL WASTE IN'I'FJiCQ'TOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID G u�1 6 -9 ( 61t,cv
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.200FT. Date Reeei t#
CL'hiss lam needmat becompleted lithe permit laforonchundred dollars
($100 mless.) WATER HEAI'FR W/VENT/F].ECTR ENERGY FEE Y_ N_
I mrtlfy that In the perfomanceaf the work forwhich this permit isissued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Callfornla.Date PND
O Applicant Date Recei t#
Z PP NEW RESIDENTIAL PLMB. SQ.FT.
Z O
NOTICE TO APPLICANT:If,seer rs'Co perhis Certificate
pro ofExemption,Labor
should become subject to the Workers'Compensation provisions of the Labor OTAL:
FIn Cade,you most forthwith comply Mthsuch provisions or this permit shall be BUILDING •E •�
Wj deemed evoked.CONSTRUCTION LENDING AGENCYSEISMIC FEE
a I herebyaffirenthat there la a construction lendingagency forthe perform- TOTAL: ELECTRIC FEE
7 Z anceofthe worktorwhlch that permit is board(Sm.3097,CIv.C3 PLUMBING FEE
02 Lender's Name
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U 1certifythat I have read this application and state thatthe above Information FEES PAID:
0 W is correct.I qmc to comply with all city and county ordinances and nate laws PERMIT ISSUANCE
7. 1 relating to Wilding cornlruction,and hereby authotlu representatives ofthla
W city to enter upon the above-mentioned property for inspection purposes. ALTERORADDMMECH.
Z
_ Date Receipt#
(We)agree to save,IndemN an d krep harMess the City y Cupertino AIR HANDLING UNIT CFO 10,000 CFM)
V against liabilities,pdgmenb, and ezpe wthi,p. in anywayamroe SUBTOTAL:
a Inst C'Yin. ft gra In fthlsa It.
1 �r
3 AIR HANDLING IINR(OVER 10,000CF.M) CONSTRUCTION TAX
Si-tuns peaontrader Date IXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will the applicant or future Wildingarvpant stomor handle hazardous HEATING UNIT(TO ID0000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
I Ieahh and Safely Code Section 25532(a)? HEATING UNIT(OVER Its,"BTU) TOTAL:
❑ Yes No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ,SQII�CE DATE
which emit W vrdous air mntamirams as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,000 BTU) pp 1991
4Yes ❑❑No ;-I
Wve read the hazanous materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Iialth k Safety Cade,Sections 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FF.
rnponsibility to notify the occupant of the requirements which most be met �L YYYY V
prior to issuanceof a Certificate of Oceupanry.
Owner or authoritreci agent Date
TOTAL: ISSUED BY_q —
OFFICE COPY