22566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing o ren: dr 22566
WMrName: One:
Lisp Elul 97$ CITY OFCUPERTINO-BUILDING DIVISIONie
Contract.' Na : Lk•No.. APPLICATION I PERMIT /
/ — BUILDING-ELECTRICALMUMBING-MECHANICAL CATEGORY CONTROL M'
Architect/Engiveer. a Lk.No:
QTY ELECTRIC PERMIT - FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑, f-1/
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that am licensed under pruwaonsof Chapter5l(commem, APPLIANCESRESIDENTIAL OB DESC ON
Ingwlth Sectbn7000)hf Divlelon3 ofthe Busircmand PrefessloneCode,and my
limneelelnfullto deffeR. PANELS
Lice. Clan Lr Licit `L '
Date Contractor "
ARCHITECTS DECLARATION 201-1000 AMPS
q�u mm Zp I understand my plana shall be used as public records. OVER1000AMPS SQ.ET. RARER $/SQ.FT.
d� Licensed Professional SIGNSELECTRICAL
< OWNCR•BNLDE0.DECLARATION
rn that I SPECIAL CIRCUIT/MISZ
z � owing rafltrmSectio 731.5,Bexempt usiness and
C.ntnctor's LicensesionsCde;Law fmthe
(ogowingreason.(Setllon703L5,Budnenand1ropm., Code;Any city or
O � TEMP.METER ORIOLE INST.
FE c.untywhich requlreaa perimt lorontmcL alter,lmprove,derrohsh,orrepalr
anystructure prior to its issuance,also requires the applicant for such permit to POWER DEVICES _
O Ble a signed statement that he Is licensed pursuant to the provisions,of the
Cont.d.e.Lke.Law(Ct piei9(commencingwithSection7000)ofDiv-
�O} xlon3 ofthe BuWmand PrefmionsCode)orthm bets exempt therefromand SWIMMING POOL ELECTRIC VALUATION
O.•!! the bash for the alleged exemption. Any violation of Section 7MI.5 by any OUTLE7SBW[TCHESFI%'1'URFS
applicant for a permit subjectsthe applicant to a civil penalty room not rre than
0. live hundred dollars(x500).
❑I,as owner of the property,or my employees with wages as their sale NEW RESIDENTIAL ELECTR_SQFT. STORIES TYPE CONSTRUCTION
Cz5� compensation,will dothework,and thestructure b not intended or offered for -
2 F 9 sale(Sec appy Busmen and Pro(mbn Code•.The ComnChls Wcerue Law
�$ whes seeodoe apply loan owner ofpropertyhis o ownemployees,
that
OCC.GROUP RFS.UNITS
whodhementss such work orate intended
hisownemplhowe providedthat gor
Improvementsarermi Intended earod.d(prole.ILhower-b deer ill have TOTAL:
' Improverrcntbwidwithln hneyearofcompletbn,tbeawner-WBderwElhave
tfaLIturden of pmving that he did ns,build or improve for purpose ofukJ. QTY, - PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT L'SUANCE
contract..to construct the project(Sec m 7044,Businand Professions Code;
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW A VEM-WATER(EA)
Wilds or Improves thereon,and'who contra os for such with a
cgellactor(s)Iimnwdpumantiothe Contnctoh Lkenw Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec B k P C for this reason
Owner Date DRAINS.FLOOR.ROOF,AREA,GOND. SANITARY Y N—
RECER T p
WORKMAN COMPENSATION DECLARATION MTURFS PER TRAP bL1IUOL TAX Y N
❑I hereby affirm that I have a clmuu to of consent d spytheure,ora RECEIPT it
3800uniLaeofWorkera'Compersatlan lruunnceoracertlflew ropythere.((Sec. GAS EA.SYSTEM-1 WCAOUTLE'S PARK PER Y N
pwl LabC)
Polfry R 100 D o RECEIPT N
C[ any GAS EA.SYSTEM-OVER d(FA) BUILDING DIV
ISION FEES
rutted copy Is hereby furnished. CREASE/INDllSRtL WASTE INTFRCEI'TOR PLANCHECKFEE
IAS.CertlOed copy b filed with the city Impcalon division.
YYsse CERTIFICATE OF EXEMPTION FROM WORKERS' GRE"A'SETRAP PAID
COMPENSATION INSURANCE
(This section need net be completed if the permit is for one hundred dollars SEWER.SANITARY-STORM EA.200FT. Date Reeel t#
(SI00)ortmJ WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
Ianet lhatlnthe person erformance ofthawork
so as tobcomermkbblued,
I shall net employ any peon In any manner n u to become subject to the WATER SYSTEM/TREATING.
Workmi Compenution Lawn of GBfomla.Date PAID
OZ ApplicantDate Recd t#
Z O NOTICETOAPPLICANT:ILaRer maki.gthts Centilcateof Exemption,you NEW RESIDENTIAL PLM% SQJrE
Fshould become subject to the Worker.'CompewUon provisl.n ofthe Labor TOTAL:
W Code,you at forthwith comply with such provisions orthis permit shall beLU '
j deemed revoked. BUILDING FEE
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafOrmthat there h a comtructlhn lending agency for the perform- ELECTRIC FEE
I
ofthe work forwhlch this permit ts issued(Sec.3097,Clv.Cd TOTAL: PLUMBING FEE
L) Lender's Name
LL ~ Lendel.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlfythat l have readthisappliallonand steethattheabovelnfornatlw -a
4 bcorred.!agree m ywilh andtyand county.tdlnancnaand state laws PERMITLSSUANCE ({-- FEES PAID.
} W relating ph ngro tmctlon,and hereby authorize mpresenlatives ofthls
1— z citym er upon/ above-m nod property for Inspection purposes. ALTERORADDTOMECH.
(We) t ve,Inde n keep harmless the City of Cupertino Date Recel t#
V again(Ba illi ,p . xpenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against d 1 t granting of this permit. AIR HANDLING UNH(OVER]0,000CFM) CONSTRUCTION TAX
Sigoa Applicant/Contractor Data f M(HAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(70100,0D)OTU) _ Date - Reeei t#
materials.de0ned by the Cupertino Municipal Code,Chapter 9.1 2,and the
I lealth and Safety Code Section 25532(a)T HEATING UNIT(OVER 11X1,000 BTU) TOTAL:
❑Yn NN.
Will the applicant orfuture bcilding occupant use equipment or devkca. VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontaMmsnts as defined by/he Bay Area Air
Quality Management D6trid7 BOILER-COMP OHPOR 100,000 BTU)
Yea I❑'I No Y
i havereadthe haza s,materials requirementsunderChapter6.95of BOILER-COMP(OYE211X1,000BTU) EPAL I
WD
the California Health A Safety Code,Section.25505,25S33 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTTALMECIi. PO'IT' AUG q
resp.mlbllity,to notify the occupant of the requl,c..to which must be met
prior to lasua ns,of a Certificate of Occupancy. -
Owner or authorized agent Date ISSUE E
TOTAL; Z
OFFICE COPY