22337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification I PERMITNO.
Buildinngddoa PN�� Lq n aL�,�v� ezz'oe,enA)0.. 22337
ens came: '1 �" AFFLICAIRA A
e-A, CITY OF CUPERTINO-BUILDING DIVISION �--� r
Contrack.e.Name: Lt..No: APPLICATION I PERMIT -2 -9
BUILDING.ELECTWCAIPLUMBINGMECHANICAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTR under S ix..,.ATLON
Ihth Sey ffurn on7QOhatAmLicensedsim3of onBusine lston,efesslwer9(mmmrnc APPLIANCL•SREWDENRAL ]OB)ESC ON
In arse i Section 70W)of d off on3o(lhegusinessand Profeepone Code,and my
licLteare lslnfull force and effect. PANELS ^ ��_F1 q
Llcenm Clam Lk.N 1�^ 1—�
Date ContractorB
ARCHITECTS DECLARATION 201-1070 AMP"' I' t
eeOQ❑ I understand my plans shall be used as publle records. OVERIODOAMPS -� SQ. ^n AR f/SQ.FT.
(/ Licensed Professional STCNSELECT'RICAL `*� II 11
Z <LLLll�lu y Or'Ism exempt
x ILDERmptfro DECLARATION SPECIALCIRCUIT/MISC YYY...///
a owing afxxs.fS tram 3IS,Bu roossaunthe ContradPmf io Llanm Law for the
Fo qqqq (oltowingichmqu SeCape7 ttommnem and Prop=e e=lfish, tl or /
on Zh'� rountywhich requBssapermleto corutrun,alter,imprwe,dertnlbh,orrepalr TEMP'MEf'FR OR POLE INST.
aa anyatmeture PrIerto W
Its uance,aleo reqbes
utheappgrant for permit to
U Ok a signed statement that he Is licensed pursuant m the provisions of the POWER DEVICES
O u.� Conlractm.License Law(Chapter 9(mmmendngwith Section 7000)ofDWI-
30 sion3o(the Rueinnsand ProfessionsC de)arthatheisexempttherefmmand SWQ,9WNG IDOL dECIRIC VALUATION
Gthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
fora permit subjects the applicant to a civil penalty of not room than
ve dyed dolom($500). NEW RFSIDENMALELECTR SQFT. STORIES TYPE CONSTRUCTION
�n owner'(the property,or my employees with wages as their sole
c pensallon,w111dotheworkandthe,tmc misnmintended or offered for
OIs(See,7004,Business and Professions Code:The Contractor',License Law
ZR dme not apply to an owner of property who Wilds or Improvn thereon,and OCC.CRO(11' RES.UNITS
who doe such work himselfor through hlsown employees,provided that such
Improvements arena Intended orot(ered fore'!,.If,however the building or TOTAL:
Improvementbeadwithinone)earofcompldlon,theowner- gderwillI ve
tFil,jiurderofpneving that he did not Wild m ireprove for purposeofule). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT 155UANC
contractors to construct the penject(Sm 70K Business and Professions Code: E 2czo
The Cont actor's License Law don root apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
build,or Improve thereon, and who contracts for such p,ojeRa with a
�'�Rl(+ctor(s)llanmd pursuant to the ContraRoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I em exempt under Sec. B k P C for Nb'sawn
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Date RECEOT M
WORKMAN COMPENSATION DECLARATION /h FIXTURES.PER 7,RAI' SCHOOL TAX Y N
❑I hereby affirm that T have a¢rugate of consent difi d self Chemo,ora V RECELPT If
3800,Lab
C.Workers'Compensatlonlnsurena oraadl(led ropythemof(Sec. GAS EA.SYSITM-1 INCA OUTLETS
policy ab CJ PARI(FEE Y_ N
I'oury N GAS FA.SYSTEM-OVER 4(EA) DING DI x
Com any BUILDING DIVISION FEE
cooled mpy b herebyfurnished,the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCIiECK FEE
Certified mpy V filed with the city inspection division.
CERTIFICATE OF EXEM PITON FROM WORKERS' GREASETRAP PAID
COMPENSATION ION INSURANCESEWER-SANITARY STORM EA 20OFr Date Reoel t#i
(fhle uctlon need not be completed lfthe pemdt to loran,hundred dollars
(SIDO)orhat WATER HEATER W/VENT/ELECTR E'NERGYFEE Y N
Iartlfy that In the performance lhework forwhlN Chi,permit bwued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSIPM/TREATING
Workere Compeneation Laws ofCaliforniaZ-Z Applicant Date Reoei tN
Z O NOTICETO APPLICANT:If,after makingthb Certlficateof Rm ption,you NEW RESIDENTIAL PLMIL SQ.Fr,
should become subject to the Workers'Compensation provlsiauof the Labor TOTAL:
CC in
Code,you at forthwith comply with such pmvbloruorthla pxmotshail be
deemed revoked. BUILDING
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lend IRS agency for the perforrry ELECTRIC FEE
Z anceofthe work for which this permit is bound(Sec.3097,CIv.CD TOTAL: t
V O t<ndar'a Name PLUMBING FEE ,
LL f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O U
UIcodifythat l have read thbappliationand statelhattheabove Information
C bmrteR.I agree to comply with all city and munty ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. W relating tobullding construction,and Mrebyaulormae representatives ofthle
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei to
V _ (We)agree to save,indemnify an d keep harmless the City of Cupertino
against ilabillies,judgments,cops and expenses which may in•nywayacvue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL'
against dCity lnro ens of the graining athh pe IL
6AIR HANDLING UNIT(OVER 10,D00CFM) CONSTRUCTION TAX
Sigmtvreof AppRant/ °°tractor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hexardoes HEATINGUMT(TOlMOOOBTU) Date Receipt
material as deBnsd by the Cupertino Municipal Code,Chapter 9.1 2,and the
I lealth and Safety Cade Section 25532(a)T HEATING UNIT(OVER 100,00)BTU)
❑ Yee No - L:
Will the a ppllcato a'Pture building ompant use equi pment or devices VENTILATION PAN(SINGLE RESID) Ig UANCE TE
which emit haxardous air contaminants as defined by the Bay Area Air
Ity Management DisMct7 SUMER-COMP F 'OR 100,Ofq BTU)
Yea nNo `y�(
havenlareaHealthe h
a`Safet Code,a lerequircmenbunderndChapter 2554.1 of BORER-COMP(OVFR 1p1,OD0 RTU)
the understand
t Health dr Safety Code,Sections currently
have
a to and,that i 1
roponcandt to
the ocgdon renamrequir haves tenant,that ltbmy NEW RESIDENTIAL MECH. SQ.FT
poor to biuly ce of a the occupant of the requirements which must be met
prior to Wuance a a Certificate of Occupancy.
Owner or authortand agent Data ISSUED BY:
TOTAL, —
OFFICE COPY