22456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
•
Building Proed Identification PERMIT NO.
Building Addresr: f717 a�
56
21 9% o.a,w.,e j G � G G 4
Phone: A
SZ' y CITY OF CUPERTINO-BUILDING DIVISION
,• /�� CD�� /��o�
APPLICATION it PERMIT
BUILDING-EI.ECDUCXl-P1iUMBINGMECHANICAL I CATEGORY CONTROL
Ire t/Engineer:- Lk.No: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLUG
Address'Pq/y0/ 8/ .fr•S.m.'4'V PERMITISSUANCE ❑'. ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(rommenc APPLIANCESRESIDENrIIAL JOB DFSCKII'IION
ing with Section 7000)of Division 3ofthe Business and ProtesslonsCo ll.rd my
I la In(uB to and dfect. PANELS
Liansc V C• C Llc M_ I -
Date �" Contractor
ARCHITECTS CLARATION 201-1000&\41-
07 I understand my pians shall W used as public remNs. OVER 1000 AMI5 SQ.FT.FLOOR AREA 5/SQ.FT.
Licensed Professional - SIGNS ELECTRICAL A'�.
GG-4 V�paa�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M]SC p � �w-�5 8 � �g'
zo hercbyaf0mlhatlamexempt(romlhcContractor'sLiceneelawfothe EVE C LJ Y E
following reason.(Section 7011.5,Business and Professions Code:Any city or
Fz TRMP.MEITI(ORI'OLE INST.
54�
county which requiresa permit toronstruct,alter,Improve,demolbh,orrepalr a1
g a any structure prior to its issuance,also requires the a ppllcant for such permit to POWER DEVICES yp�rs
E V file a signed statement that he It Elansed pursuant to the provisions of the
Contractor'sLicense Law(Chapter 9(romrruncing with Section 7000)of Divi SWIMMING POOL Fl.RCTRIC
VALUATION"
ppF�O< slon3ofthe Buslnessand PmfcsslomCWe)orthat heisexempttherefromand
the basis for the alleged eaemptlon. Any violation of Section 7015 by any OUTLElSSW17CHESFlKTURES
CL' appllcant(ora permit subjects the applicant to a civil penalty seta more than
A, five hundred dollars($500).
'
,$ NEW RESIDENTIAL ELECTR SQFr. STORIES, TYPE CONSTRICTION
�n ❑I,as owner of the property,or my employees with wages r thele sole
compensation,Boldo the work,Profes ions Code:
he Contintended or mme offered L for
w
� O doe( c.notappy to an ower Professions Co Wilds or improves
Ucense Law
(jS$
does apply rkhi 1fr tisproperty who Wmply..p eidh t .tcon,and OOC.GROUP RIS.UNITS
C. wpmdovsntsamkhimsedMorargh hlsowle.Ityees, er,thedthatwch
improvemantsarerwtintendneyearoe mpletile.theoweveplhe WlWl have TOTAL:
improvement baold within he did of completion rove fo purpose of sahave
the j L as o nprerfing ee of the property,
did eta excluuild sively co for purpose acense QTY. PLUMBING PERMIT FEE FLOODTDNE APN
Lf L as owner tr the property,am exclusively Business
Prowith Ikon d / PERMIT ISSUANCE Q.00
contractors to roriswct the project(Sec.70,14,Business and Professions Code: '
The Contractor's Lienee law does rut apply to an owner of property who ALIER-DRAIN&VENT-WATER OW
or Improves thereon,and who contracts for such p(ojects with a FEE SUMMARY
If,son
Band pursuant o the Contractor.License Law. BACK FLOW PROTECT.DEVICE am exempt under Sec B&P C for this realon
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N �I S I
. RECEIPT
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
0
1 hereby alflrm that!have a artlllcate of consent to se161nsure,ora RECEIPT 0
MW LabC)ofWorkers'Compensatlonlnsurana ora art(fied copy thereof(Sec. GAS EA.SYSTEM-1 WCAOUFUT5 PARK FEE V N
3800.La _ —
Polley M_� RECEIPT X
Com any_y' IVR: GAS EA.SYSTEM-0VER4(EA) BILI LDI NG DI VI SION FE ES
�Ccitified copy la hemby famished. CREASE/INDUSTRLWASTEINTERCEPTOR PLANCHECKFEE
,�Cenlfled copy is filed with the city inspection division.
-- CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- RM EA.200FT. S.O D Date Recei t#
(rMaeccti.n need not Wcompleted Rthepermit CE one hundred dollar STO
($100)mless.) ENERGYFEE Y_ .N
I artlfythat in the performance ofthework for which this permit is issued, WATRRHE_ATFRW/VENT/F1.ECTR
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. SQFr. Dale - Recei t#
ZO NOTICE beco.APPLICANT: aReers'Comarmaking this Ction press Exemption,you
Fshould become subject to the Worken'Compensatlon provisions.(Rise labor TOTAL:
N moat forthwith comply with such provisions or this permit shall be
LU Cale,j deemed revoked,_ Pmv BUILDING •E
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirenthat thea La a construction lending agency for the perform- ELECTRIC FEE
Z ante of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL: 700
(,) O Lander'.Name PLUMBING FEE /7.0 O
I— Landers Address - QTY. MECHANICAL PER... FEE
Wl artlfythat have read lhisappllcationand gate thatthe above Information MECHANICAL PEE
1 damrrect.I agreeto comply with all city and county ordinances and orate laws PERMIT ISSUANCE FEES PAID:•
>_ IL to building mnstructlon,and hereby authorise representatives ofthls
F N cityto enter upon the abovementioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree t.save,Indemnify an d keep harmless the City of Cu pimin. Date Receipt#
V against liabilities,judgments,consand aspens.which may In any way marine AIR HANDLING UNIT CTO IDp00 CFM) SUBTOTAL:
agaloaapaId City run he granting a this permit '
�,f� AIR HANDLING UNIT(OVER IO,000CFN) CONSTRUCTION TAX
�`1 o CONSTRUCTION TAX PAID:
'g turn. Applicant/Contractor - Date alLsus'r HOOD(W/DUCT) "
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture budding occupant store or handle haurdoua HEATING UNIT DO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Ikalth and Safety Code Section 255324)? HEATING UNIT(OVER 100 •
,000 BTU) TOTAL: 7.00
Q Yes MN. 1-
Will the applicant orfutom Wilding occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit hasurdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,IX0 BTU) P a p
Qys nn No
e mad the hasamous materials requirements ander Ghapter6.95 of BOILER-COMP(OVER 100,000BN) •! /y
the California Health&Safety Code,Sections 25505,5533 and 25531. I .QQ /jya/�p
understand that lithe building does nor currently have a tenant,that it is my NEWRFSIDENUALMECH. SQ.FT.
responsibility prior toissuance
ofsCeheocte of o(therequlrementa which must be met \ (
issmnce.fay the occupant
lief the racy. - A�
Owner or authmired agent Data TOTAL ISSUED BY:�.
OFFICE COPY /�