22699 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Add a:H.
P,ojec'Identification a - 'W PERMITNO.
ao Gia 22699
s ame: one. A,=A
CITY OF CUPERTINO-BUILDING DIVISION b
C actorur.Nel: APPLICATION / PERMIT (mob
0 d BUILDING-ELECTRICAL PLUMBING-MFCHAMCAL CATEGORY CONTROL N
lir.
A h Lic.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG EL�l PLUMB Mk�ll
Address: PERMITISSUANCE El Ej 1:1LICENSED CONTRACTOR'S DECLARATION
]hereby.a((Ins that lam licensed order provWoro of Chapter9(m.c, APPLIANCES-RESIDENTIAL JOB DfSCRE'fgoN
ingwlth Sectlo,7000)of Dlvig=3ofthe Busmmand Profs ms Code,and my
license is infu d effect. O PANELS
Limn CbnLlc M
Date' CUP 10 200 AMPSS
ARCHITEnciantCT'orSC ` p1-1000 AMPS
IONS
Qww 7O 1 understand my plane shelf be used m public mcurda OVER 1000 AMPS SQ.FF.FLOOR ARG 8/SQ.FT.
m V 6 Licensed Professional SIGNS ELECTRICAL
<cw. OWNER-BUILDER DECLARATION A IN
j Ihambyaf0rmthatlamexempt fromthe Contractor'sLlcense Lawforthe SPECIAL CIRCUIT/MLSC ff 666���
0 9 following reason.(Section 7031.5,Business and Professions Code:Any city or TE[P METER OR POLE INST. /,
county which requires a permit toconstruct,alter,improve,demolish,or repair 8171 1
qm any structure prior to its issuance,also requires the a ppllant for such permit to POWER DEVICES
r'5 m file a signed statement that he b licensed pursuant to the provisions of the
FQj OCL Contnaara License saw(Chapter9(mmmencingwith 5Mbn 7000)of Divi- SyyPLYENGFOOLELECTRIC DA
30 sbn3ofthe Bugnessand Profmss mCode)orthathelsexem therefmmaed
a O•� the basis for the alleged exemption. Any violation of Section 7WIS by any OUTLETSSWIXFH FIXTURES
g applicant fora permit subjects the applicant to a civil penslly of not more than
five hundred dollars($50B). NEW RESIDENTIAL ELECTR FT.
❑I,a owner of ted property,or my employees with wagca as their cols S[OWFS TYPE CONSDiIJCTION
k7a compensation,wllldothe work and thestructure brmt Intended or offered for
p sale(Sec.7044,Businessand Professions Code:The Contractor's License law
$$ does not apply to an owner ofproperty who Wilda or improves thereon,and OCC.GROUP RES.UNITS
whodoessuchwork himselforthrough hlsownemployan,provided that such
Improvements are not Intended oroQeml for sale.If,however thebuildleg or TOTAL:
improvement lssoidwithln oneyearofcompletionthe Owner-buaderwill have
tht burden of proving that hedid notbuild orimprovefurpurposcofsele.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project m(Sec.7014,Busineand Professions Code:
The Contractor's License law don not apply to an owner of property who
builds or improves thereon,and who contracts for such Inpjects with a ALTER-DRAIN&VENT-WATEt(G)
gq�0l1R[adone11censedpumuanttotheContractor's License Law. FEE SUMMARY
cui am exempt under Sea B&P C for this mason BAIX FLOW PROTECT.DEVICE OUTSIDE ECS
DRAINS-FLOOR RODF,AREA,COND. SANITARY Y_ N_
w
• Oner Date RECEIPT p
WORKMAN COMPENSATION DECORATION FTXNRFYeL _S PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a mrtiicete of consent to self4esure,ora RECEOR'N
38�flubCO'Work sCompensationWunnceoracertl(Iedropythereo(Sec. 1 GAS EA.SYSTEM-1INCA OUTLETS I PARK FEE Y_ N
Policy N 7 RECEBFT N
Cee any GAS.F.A.SYSTEM-OVER 6(G) BUILDING DIVISION FEES
f_J Ceetifcd copy b hereby furnished. GR[ASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ls filed with the city inspection division.
CERTIFICATE OF E(EMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G 200F[ /'1. IT.W R1 t#
(This section need not W completed lithe permit b for one hundred dollars
($100)orless.) WATER IiFATEft W/VENT/ELFCTR ENERGY FEE Y_ N_
I certify that In the performanceof the work forwhich this permit la owed,
I shall not employ any person In any runner so as to become subject to the WATERSYSTEM/TREATING
Workers Compensation laws of California.Date PAID
O Z RESIDENTIAL PCMB. SQ.FT.
Applicant Date Recei t#
Z NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you NEW
should WcomesubjM to the WorkerCompensation provlsions of the Labor TOTAL:
Code,you at forthwith comply with such provisions or this permit shell be G W BUILDING FEE
deemed revoked.
Ill U� �w C/p�
CONSTRUCTION LENDING AGENCY 7`•'•�V SEISMIC FEE
d Ihereby affirm that them is a construction lendingagency forthe perform- TOTLECT
RIC FEE
M Z ince ofthe work for which this permit Ls Issued(See,3097,Civ.C.) PLUMBING FEE
V O Iander'sName
1L F Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL ITE
U 1certifythat i have read this application and state that the above Information
O W lscormct.I agree to comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID:
misting to building construction,and hereby authodu mpresemativn ofthls
F city to enter upon the above-rrntioned property for impectlon purposes. ALTFRORADDTOMECH.
Z (We) Receipt#
_ (We)ag.to save,Indemnify an d keep harmlem the City of Cupertino
against liabilities,pdgmenta,cegaand expe whicherayi anywayaocrus AIRHANDLING UNIT CFO 10,"CFM) SUBTOTAL:
-meId Ci ,�irr.t cogag� enee 'the Bra in fthb pe R' CONSTRUCTION TAX
` � %' — `^,ne )eq �' AIft HANDLING 11MT(OVER 10,000 CIM)
Signatu re of Applies/C//C'o_onntlracor}l..Lx1�CUS_/ 4,Daate IXHAUS'T How(W/DUCT) CONSTRUCTION TAX PAID:
HALL R DOUS MATERIALS DISCLOSURE
Will the a ppllant or future building occupant store or handle havrdous BEATING UNIT(TO 100,810 BTU) Date Recei t#
mrtedaI as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the
Healthand SafetyCede SectionM324)i HEATING UNIT(OVER IDg000 BTU) TOT L•
❑ Yes M No
Will the applicant or form,building Occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISS DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management District? BOTLFR-COMP OEm OR 10000 BTU) Cpl
4havereadthe ha endousomaterialsrequlrenartsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) ( ( "�s
1991
the Ca lifmia Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT as(
responsibility to nany the Occupant olthe ilrcmentswhich must bemet YL�'IIs!"%I F`P*
It,lssuanc 'f ate o/ capon'.
��
senor authorise est Data ISSUED BY:
TOTAL:
OFFICE COPY
ADDITIONAL, PERMIT FEES
BUILDING PROJECT IDENTIFICATION VALUATION
BUILDING
"DDPE55�\ mpez PW L
HAVE
"NE [ � FEE SUMMARY
J ONE
CONTRACTOR s BUILDING
N..E
LIC.NO. PLAN CHECK
CorvmaTOns FEE
ADDRESS
PHONE SEISMIC FEE
DTV. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VAUDATION
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Z Z
p a TOTAL
CC y ISSUANCE DATE
UJ > OTV. PLUMBING PERMIT FEE SLOG. E ff. vLc. MECN.
Z) Z ALTER DRAIN&VENT-WATER
V O BACK FLOW PROTECT.DEVICE
O IU DRAINS-FLOOR,ROOF,AREA CONE).
N FIXTURES-PER TRAP 1 /
F ? GAS-EA.SV STEM-11NC.40UTLETS W
V GAS-EA.SYSTEM-OVER 41EAJ
INDUSTRIAL WASTE INTER. OG rJ A A i T
LAWN SPRINKLERS 1 INC 5 V.B.
LAWN SPRINKLERS-OVER 51EA.1
SEWER-SANITARVSTORM EA.200f[/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP. .«O
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE qq
AIR HANDLING UNIT ITO 10,000GF.14) Ar
AIR HANDLING UNIT(OVER 10MC.F.M.) &IA
0
EXHAUST HOOD(WITH DUCT)
HEATING UNIT LTO 100,000 B.T.U.) R I�rl 1992
HEATING UNIT(OVER 100,000B.T.U.) Uuf,
VENTILATION FAN(SINGLE) �h�l�'U
M
COMP 13 H.P.or 100,000B.T.U.1
-COMP IOW,100.DDU RTU)SEE FEE SCH.
TOTAL