22867 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
—_Building Project Identification ILw
PETNO.
Building Add 70w
22867 2 8 6 7
Phone:
9 k! CITY OFCUPERTINO-BUILDING DIVISION
C a or'eNarr Lie N": APPLICATION If PERMIT �l
BUILDING-ELECIRICA4PLUMBING-MF MCAL CATEGORY CONTROL
ArcM1ltect/En Llc.No:
1� BUILDING PERMIT INFO
\\C� CA_, 1 QTY ELECTRIC PERMIT FEE
Address: Jv NTRAC7 PERMITISSUANCE ❑ ❑ �/I ❑
LICENSED CONTR imeter SDECLA TION LIO
I behseakiirmthat dDiv Bl 3o funder provislo I2rpfe kxmC(mmmene APPLIANCES-RESIDENTIAL JOB DFSCRIrITON
inense1Sectfun 7000)ofd off:n3ofthe Bugn a �p(esslonsCode,and my
LlcensulClass I(oma and kfect. '77 TT PANELS 1
Late Contractor j7$o�
ARCHITECPS DECLARATION X11-1000 AMTS
OX I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
O
Gcenscd Profaeloal SIGNS ELECTRICAL
�Q OWNER-BUILDER DECLARATION
rn SPECIAL CIRCUIT/MISC
Zf, Ihcrcby a(fimntha
atlm exempt wmthe Contractorb Llttnse Law for the
following reason.(Section 71111.5,Busload and Professions Code:Any city or
O F.. TEMP.METER OR['OLE INST.
Fog countywtchreorto it pertNttoronswetiresth, aprovgt for
to
���[[,,� anyswcture prior to its Luuance,aWrequlrntheappRant for such permit to POWER DEVICES
K file a signed statement that he is licensed pursuant to the provisions of the
�O�O Contactors License law(Cha r9(comrrcnCn with Sectlon 7n W)of Divi- VALUATION
^ sion3 ofthe Business and PrefessioraCode)cribs,he in exempttherefromand SWIMMING POOL ELECTRIC
6 5 the beats for the alleged exemption. Any violation of Section 703L5 by any OUTLETSSWITCHES.FIXTURFS
66 applicant for a permit subjects the applicant to a civil penalty of not more than
c. five hundred dollars(A500). NEW RESIDENTIAL ELECTR
.- ❑I,as owner of the property,or my emsployeewith wages as their sole `"Q�' STORIES TYPE CONSTRUCTION
C�< mmpensatlon,wdl dome work and thestrucwre is not intended or offered for
y�p dale(Sec.7044,Bumnea dna rroreamns Inde:The Cnnaactnr.uanse law
�$$ does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RES.UNTfS
who doessuch work himself orthrough hisownemploym,provided thatsuch
improvements are not Intended oroffered formle.If,however,thebullding or TOTAL:
improvement insold withinoneyearofcompl&bgtheowner-builderwill have
th,L4urden of proving that he did not Wild or improve for purpose ofsaled. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L_j L as owner of the property,am exclusively contracting with licamed PERMIT ISSUANCE 500
contractors to construct the project(Sec.7044,Business and Pretentious;Code: .7/
The Contractors License Law dm nes apply to an owner of property who
builds or Improves thereon,and who contracts for such pi jects with a ALTER-DRAIN&VENT-WATER(EA)
cgDl�+ctor(s)Bomeed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I Ire exempt under Sr. B&P C for this reasonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT N
WORgNAN COMPENSATION DECLARATION FIXTURES PER TRAP SCIIODL TAX Y_ N_
by affirm that I have a certlRate of consent to self-loom,ora RECEIPT N
rtTRttteofWorkeri Com PC east 6if"copy themof(Sec. GAS EA.SYSTEM-1 WC.4OUTLETS PARK FEE Y_ N_
M00.lab C.) fd /u udna or RECETIER
Poiicy 0 GAS EA.SYSTEM-OVER 4(EA)
Com any VAC Q�'1tL.P BUILDING DIVISION FEES
led copy Is hereby GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
j]Certifled copy b filedhere withth the day Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.XIOFI. Date Remi t#
(Thlssectlon need not be completed if the permit efor dee hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR O ENERGY FEE Y_ N_
I meily that in the performance of the work forwhlch this permit Is issued, a
1 shall not employ any person In any manner so a to become subject to the AWATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RF9DENT AL PLMB. SQ.F7. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
~ N Code, most forthwith cam 1 with such provisions or this permit shall yu""'"a Py P pe BUILDING EE
LU j domed revoked.
a o CONSTRUCTION LENDING AGENCY SEISMIC RICF
Ihereby afrk forthat with is thiaconstmctlsued(Sc. agency for the perform TOTAL: ELECTRIC FEE
ZO anceof ei's Naork!or which thin permit is Issued(Sec.3097,Civ.C.) 1
Lenders Nme PLUMBING PEE
LL F Lenders ndamss QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I dilythittl have read thisappllatlonand gate that theabove Information
incorrect.I ageato comply with all cityand county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} y relating to building construction,and herebu yauth"rlrepresuntatNesof thin
F city to enter upon the abovcmentloned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnl/y an it keep harmless the City of Cupertino Date Receipt#
V agaiat liabilities,judgments,mgaand expenses which may In anywayaceae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid City In consequence of the granting of this permit.
MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the alicafit or future building recu ant store or ha fid to hazardous BEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the _ Date Recei f#
health and SafetyCode Section ZS533(a)P HEATING UNIT(OVER 100,0W BTU) TOTA
YnNo
Wllltheappilant or tore builiingoccupant use equipment or devices VE ILLATION PAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air pp�� pp
QuWI
Qua lily Management Dct7 BOILER-COMP(31IP OR 100,DM BTU) lP M
Yes1�ll No
have readthe havrousmateriabs requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000B'M
the
ersta dta tlith& ildin Code, etcuantlyh veate nd ant that it FED 11 1992
understand Halt&&Safety
building does net currently 25505,25533 tenantthatt9 my NEW RESIDENTIAL MECH. SQ.FT
rapmnsibility,to natty he occupant of the requirements which must beret
p' r Issues a duiitcof OCcupa
CITY Or Wrtrliuv
nc o authod a cnate TOTAL: ISSUED BY
OFFICE COPY