22916 -� APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22916
hone
CITYOFCUPERTINO-BUILDING DIVISION /� �
Contractor's Name: LIe. / ./a�D�f No: APPLICATION PERMIT L
A&V ' 1 0"7p 1 BUILDING-F].F MCALPLUMBING-MEC)1AMCAL CATEGORY CONTROL N
ArcMtect glneer. ^ Llc.No:
G/6/ i✓//�� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 5;�y/Jt9 Le� t^0 S
PERMITISSUANCE 11 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby 70 that lam Bcenaedunderinessa dProfessions 9(ft,and c APPI3ANCESAFSIDEN]'IAL ]08 DESCRIPTION
iI...hSection 7000)of DlWalon3ot1he8u9neasci Pra/ealo.Cade,and my ` . , `��W
liconse Isis full fo r�d Mfect r� a— PANELS �'M
Icense Cis — 1LkN •
Date Cc dor .Cart o-cesUP TO 2DOA5
ARCHITECTSDECubhereON OVERIODOAM75 SQ.Fr.FLOOR AREA E/SQ.Ff.
�ppµ+�;� Z I understarW my pia.ahaB W used as public records
E f t Licensed Professional SIGNSELECTRICAL , �, E D
7�16 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
'GI hereby affirmthat Iamexempt from the Contractor'sLicense Law fmthe M P U T E
Q following reason.(SMIon 70315,Business and Professions Code:Any city or TLMP.METER OR POLE INST.
FPty countywhichrequlmapermittoco.tmd,ilter,bnprove,dertnlbh,orrcpalr / 3 ,
a`a 7Q anystruccure prlorto its issuance,also requlrcsthe applicant for such permit to POWER DEVICES [ / —/
6 V file a signed statement that he N licensed pursuant to the provisions of the
Contractor's License LAW(Chapter9(commencingwhhSection7000)ofDlvl- SWDAMNG POOL ELECTRIC F4, VALUATION O sion3ofthe Bus(nessand ProfewWm CWe)orthathebexemptthemfromand
5 the basis for the alleged exemption. Any violation of Section 70HS by any OUTLETSSWITCHESHKTLRFS 2 O V �^
applicant(ora pemdt subjmatheappecant toes civil pe.lty of sat mare than
a. o five.hundred delta.(S500). NEW RESIDENTIAL ELECTR SQPT. STORIES TYPE CONSTRUCTION
L Z 6 ❑1,as owner of the property,or my employees with wages as their sole
mmpemation,wel dothe work and thestnrcture is nes intended or offend for
0 sale(Sec.7044,Business and professions Code:The Contractors License Law
�r3'$ does nes apply to an owner of property who builds or improve thereoRand OCC.GROUP RFS.UNITS
whodoessuchworkhimself orthrough hisownemploym,provided thatsuch
improvements am nes Intended oroftered formic.If,howeveq thebullding or TOTAL:
improvement issold withinoneyearorcompletiontheowner-builderwill have
th rdenof proving that he did not Wild or improve forpurposeofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
�
G as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contractors to cootrud the project(Sec.7044,Business and Professions Code:
The Contractor's License law,don out apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
Wilda or improves thereon,and who contracts for such piojects with a FEE SUMMARY
ogitfador(OB.O.d.pmuoutt to the Contractor's Ll...Law. BACK FLOW PROTECT.DEVICE
LJ I am mffipl under Sec B k P C for this reasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
. Owne Date RECEIPT N
WOR"AN COMPENSATION DECLARATION FDCIURES PER TRAP SCHOOL TAX Y N
T hereby affirm that I have is certificate of consent to sell-litsure,or REC®sF N
certificate or Workers'Com . o
pealiInsurance ora certified copythereof(See. GAS EA.SYSTEM-11NCAOUTLEIS PARKF'EE Y N
Policy
_
ic Lpb CJ _ 3�Z RECm'fN
Com any ��// OO GAS FA.SYS[EdOVER 4(EA) BUILDING DIVISION FEES
ed copy Is hereby furnished. F ` GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
0Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700FT Date RCOCI t#
(Thlssection need nes be,completed If the permit is forone hundred dollars
(3100)orl..) WATQ4IiFATF74 W/VENT/m cr.I.R ENERGY FEE Y_ N_
1 certifythat in the performance of the work for which this permit is usued,
I shall not employ any person In any manner so as to Wcome subject to the WATERSYSTEM/TREATING
Workers Campensatlos Laws or California. Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQJiT. Date ReceI t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
FN should becomesersubject to the WorkComperuation provbiory of the Labor TOTAL:
CC
0 Code,youmustfomhwRhcomplywitn chprevbb.orthispemdt shallbe BUILDING ••E
W _ doomed revoked.
colvsrgucrlo LENDING AGENCY SEISMIC FEE
a Ihembyaffirmthat th is Imdlon lending agency for the perforrry TOTAL: ELECTRIC FEE
Z once of the work forwh t t is issued(Sec.309],Civ.C.) PLUMBING PEE
L) O landera Name
LL F I.eMera Address - QTY. MECHANICAL PERMIT FE MECHANICAL FEE
O W Icertifythatlhavercad hbapplieationand stmethatthsabevelnformation
brm
1 coet.I agree to comply with all city and county ordinances and statelaws PERMIT ISSUANCE FEES. _Prat / 2
relating to building co.truction,and hereby authorize representativesentrue B 1 O
Z cityto enterupon the above-mentioned property for impeccion purposes. ALTPROR ADD TO MFGH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which mayin anywayacerue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said City In consequence of thegra his permit
� 'f ear AIR HANDLING UNIT(OVER IO,ODOCICONSTRUCTION TAX
M)
CONSTRUCTION TAX PAID:
Signature o(ApplHAZA HAZARDOUS MATER
a IXliAUST HOOD CW/DUCT)
HAZARDOUS MATER SUISCLOSURE
Will thea applicant or future builiin ant store or hand le hazardous HEATING UNIT 100,000 BTU)
PP P Date Rcceip[#
metotialas defetyCodthe Cupertl unidpa e,Chapter 9.17,and the
}IE-1 Yes Safety Cade&din 32(ap HEATING UNIT(OVER ID0,000 BTU) TOTAL:
Yn
Wilenut hicardntorr tout ng occupant use the Bay Area devkes VENTILATION PAN(SINGLE RESID) ISwSUA�CG)ATE
Which eMthazarent air cont .meas defined by the Bay Area Air
Ir b� lVl
Quality Ma.gement Dist BOILER-COMP OFBsOR 100,000 BTU)
4Yas No 9
have read the hon sus materia6 requlmmenh underChapter6.95 of BOILER-GQMP(DVER 300,000 BI'U) OCT 2 " 1991
the California}IcalthkSafety Code,S io.25WS,75531and75534. I
understand that if the building does not currently have a tenant,that it is my NEWRFSIDENITALMECH. SQ.Fr.
responsibility to notify the occupa at of the requirements which must be and fsl 1pEtIIINU
prior to Issuance W a Certificate of CI I Y OF CUP
Owner or authorized agent Date TOTAL: ISSUED B
OFFICE COPY