22795 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addms: "16it-t0O k PrV_4*R**-3 ; AVE 22795
neva 773one: Y A
S%vp CITY OF CUPERTINO-BUILDING DIVISION
contra LteNo: APPLICATION / PERMIT
dC ,J�/��/y 7 BUILDING-F3.ECTRICALPLUMBING-MECFIAMCAL CATEGORY
Architect/Englneer. [tie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE T�/I
LICENSED CONTRACTOR'S DECLARATION L�
Ihereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL )O DES, ON
Ingwlth Sec90 o Aston3ofthe Bustnessand Pmfe ionsCode,andmy JA
lit. s `oqc and le.. PANELS
LI C n LIG N A 40
Il�l•�l.
ate Contactor ..�_ B AMPS
ZF
ARCHITECTSACLA 10 VERIWO AMI'$ SQ.FT.FLOOR AREA $/SQ.Fr.
re0 2 I understand my plans shall be used as public records
�O SIGNSELECTRICAL
j Licensed Professional
OWNER-BUILDER DECLARATION SPE-CIALCRRCUIT/MIBC
t.., g Ihercby afnrm that l am exempt from the Contractor's License lawfar the
p _ following rezaon.(Section 7031.5,Bu,lnns and Pmfevbv Code:Any dtyor TEMP.METIX OR POLE INST.
F45, cauntywhichrequimsaperMttowmtmM, tegUpmvedemollsh,orrepair
.� anystmMmpr rtolOLt,sane,alorequimtheappUrantfwwchpemdtto POWER DEVICES
file a signed statement that he is licensed pursuant to the pmvlslores of the
Contractor's License law(Cha(Chapter withSect1on70M)ofDlvl-
Pt 8 SWIMMING POOL ELECTRIC
1-30 Rt elon3of<he Business and Pro(emlora Cade)wthat heisesemptthere(romand ' NVALUATION
O tBusinesshe basis for the alleged exemption. Any violation of Section 7015 by soil
UH.ETSSSWITC F FIXTURES Z ) 'N� Ms �•.
irud applicant fora permit subjedseheapplicam too civil penalty of riot orethan 611
Ri five hundred dollars($509). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employeea with wages as their sok
compensation,will do the work,and the structure is net intended or offered for
Osale(Sec 7044,Business and Profealons Code:The Contractols License Law
j$ does not a pply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
whodoe,suchworkhim Iforthrwgh hlsownemployees,provided thatsuch
improvemenb are act Intended oroffercd forsale.If,however,thebuilding ce TOT
improvement issold within oneyearofcompletion,the owner-builderwill have
theLkurden of proving that he aid not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec.7N,1,Business and Profeadons Code:
The Contnctor'e Llcenae law don not apply m w owner of propertywho TER(FA]
Wilds or imERM
prwes thereon,and who comment for such projects with a ALTER-DRAIN VENT-WA
m,itl1tt((ctor(s)eear sed pursuant to the Contractor's License Law. FEE SUMMARY
LI I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEIIS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES I'ER•[.RAI' SCIi00LTAX Y_ N_
[—]I hereby affirm that I have a wn10c to o!consent to seB-[acorns,w a RECEIPT N
wnifiuteofWorkers'Comperuationlruuranwora¢nifledmpythenwf(Sec. GFA.SYSTEM-IINCAOUILEIS PARK FIE Y N
3800,Lab C.) ASRECEIPT M
Polity N GAS FA.SYSTEM-OVER 4(EA)
Com any BUILDING Ill VISION FEES
MMI'lled copy b hereby furnished. GREASE/INDUML WASTE INTERCEPTOR PLANCHECIC FEE ^ /t
❑Certified copy is inspection with the city pection division. is mItB
TI
CERTIFICATE OF EXEMPON FROM WORKERS' GREASE TRA[' PAID
COMPENSATION INSURANCE SEINER-SANITARY-SroRM EA.2(K)FT. Date RCCeI ted
section
sion need not be completed if the permit Is forons hundred dollars
($100)orlea.) WATER HEATER W/VENT/D.ECTR ENERGY FEE Y_ N_
1 rectify that In the performanceof the work forwhich this permit Is issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Wonkers'Compensation Laws of CaORtnis.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei HI
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
H� N should become subject to the Worken'Compensation provisions of the Labor TOT;
Code,you must forthwith comply with such provisions or this permit shall be B I
deemed revoked.
LU CONSTRUCTION LENDING AGENCY SEI 'E I / —
d e Ihembyaffirm that there is a construction londingagenry fortheperform, TO16� ELE C �•�
7 Z anmoftheworkfor which this permit is Laued(Ste.3097,Civ.CJ PLUM [ISG FEE
(� O lender',Name
LL F lamer,Adarea. QTY.I MECHANICAL PERMIT FEE MECHA L '
OW Icertilythat I have read this applicationand siatethatthe above Information
1 ismrred.Iagrce to comply with all dty and many ordinances and statelaws ` PERMI7ISSUANCE FEE P D:
relating tobulldtng comuuction,and hereby authorize representatives of this
Z cit to entero the above-mentioned for inspection sea. ALTQRORADDTOMECH.. �� ate R ClPtll
~ y(We)agree to save,Indemnify an d property
harmless te City of Cupertino
V
a'aImithatdbtlra,jrdgments,coatsand expenses which may in anyway accrue AIR HANDLING UNIT(r010,000 CFM) SUB T TAL:
ag sa Cuyi a roof the%g/r�_ting�ofthla parmfa' CONSTRUCTIONT
/L ///Z AIR HANDLING UNIT(OVER tO,ODOCIM)
SIgmturcofArat/cnno-adnr Date FxL-uusT ooD /Duch �� CONSTRUCTION T X PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the 41511cant.rfumre building oavpant store cur handle havrdous HEATING UNIT(TO 100,0006N) Date R CI t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section M532(a)7 HEATING UNIT(OVER 100,000 BTU) TO
❑Yea I]No
Willthe applicant or future building occupant uneequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Ab
Quality Management D❑istrict? BOILER-CAMP QFE'DR 100,000 BTU)
4Ys NNo
have read the hazy u,materialsrcqulmrrenb under Chapter 6.95 of BOfQR LER.COMP(OV100000, BTU)
IPA
p�,
the California Health&Safety Code,Sections 25505,25533 and 2x534.I 1P A � V
understand that if the building does not currently have a tenant,that itis my NEW RESIDENTIAL MECFI. SQ.FT
rnponsibllity to notify the ocmpant of the requlrerta:nts which most be met
prior to Lauan a Ce Ific to of Occvpa Orf `z 0 1991 LQ
p
Owncrorauthodze eat' / Date / ISSUEDB .
TOTAL.
4 OFFICE COPY