22920APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project IdentificationPFI
Building Add
MITNO.
22920
where FEE, s: i
�L�Z ZJ
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECTRICAL-PLUMBINGMECHAMCAL
L "6
cont tt r' N°:
CATEGORY.
CONTROL#
Architect/Engineer. Lle w:
QTy ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrero
❑ ❑ ❑
I'FRhETISSUANCE
LICENSED CONTRACTOR'S DECLARATI
I herecrflon 0thatl licensed erprovbions aptar9(mmmen
h...lrgwfthSection fee. fgviolon3wfthe Busl ro(eWopeCode,and my
license ie in full force d(
APPLIANCES -RESIDENTIAL
JOB DFSCItIIaTTON
PANELS
Llcen c.#
Date ntraaor
UP TO 2DO ANTS
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plana shall be used sat public records.
OVER1000AMPS//��
LF[e ajJSTA 5/SQ. FT.
SECNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby of lrenthat I am exempt fromthe Contractor's License Law for the
AA�'..JJ\\
SPECIALCIRCUH/MISC
TEMP METER OR POLE INST.
following reance.(Sectlon 7(ELS, Business and Prefeolons Code: Any city or
countywhich requires a Parrott tomretruct, alter, Improve, demalish,oreepalr
^#
!ITEF;
sa��
anyetmaure pdorto lb issuance, also requlrestAeappllant (orsuchpsmnuto
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Cha pter9(rommencing with Section 7000) of Divi-
3ofthe Business and Predessimu Code) or that he b exempt thereftemand
POWER DEVICES
SWIMMING R70L ELECTRICsion
VALUATION '
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of no morethan
OUTLETSSWITC1iFSFIXNRFS
O O O
NEW RESIDENTIAL ELECTR SQJrr.
flue hundred dollars he .
❑Las owner of the property, of my employees with wagro as there door
STORIES
TYPECONSIRUCION
compensation, winkand isnot Intended
Buldothe
ionsCde:
Lt.. Law sale( Sec 7654,
Code: The Co sL Lw
to anoss wandf property
doewhorl apply torkhinrorth property emplIlds riepp.itheteon.and
mprear arson
whodoes em ployees,providedlhatsuch
OCC.GROUP
RES UNITS
ntga nr inseBorthmffe dfo
Improvementsarenotintended earofco !wreak.If,h ner-6ihebuiilI have
Improvement bawls withinoneyearo(compldioMtheowner-bullderwlll have
TOTAL:
the burden of proving that he did non build or improve for purpose of sale.).
0 L as owner of the property, am exclusively contracting with licensed
contractors to eonstNR the project (Sm 7044, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
Pf.00D70NE
APN
The Contractor's Licenx Law dm not apply to an owner of property who
builds or Improves thereon, and who contacts for such projects with a
cgptpctor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B k P C for this mason
ALTER -DRAIN &VENT - WATER (FFaV
FEE SUMMARY
BAER FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of ..at to self4raurs, or
certificate ofWorkers' Compensation Insurance or a certified copy thereof Ciec
381),Lab C.)
SCHOOL TAX YN
_ _
RECEIPT_NM
CAS EA. SYSTEM-11NC.6 OUTLETS
PARK FEE Y N
Policy #
RECEIPT M
GAS E.A. SYSTEM -OVER 4 (EA)
ny
RUIL DING DI VISION FEES
ehified copy is hercbytumecity
Canihad copy b h rd with the city inspection dlvirlon.
CREASE/INDUSfRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMeoedion need not be completed tithe permit b (°cone hundred dollars
PAID
Date Recei tot
SEWER -STORM -STORM EA. 200FT.
WATER HEATERW/VENT/ELECTR
ENERGYFEE Y N
PAID
(El1))rtifytd an person In any annex so as to b cornhis permit b issued,the
Ill not that emin ploy
I shall not employ any prawn In any manned so u to become arbJed to the
'Compenon lawn of California.lifoATER
Workcnud lllo . Date
SYSTEM/TREATING
ApplicaNOTICE agermakingthiosaket proist. Of Exemption,ayou bo
shoulNOTICEco egibpC to
become to the Workers' CompevatbnpmWlopeofthelabor
Date Recei tot
NEW RESIDENTIAL PLMB. SD}T.
TOTAL:
Code, forth
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
..w
BUILDING FEE
SEISMIC FEE W3 49
CONSTRUCTION LENDING AGENCY
I hereby a((irmthattherc bacopetruction lendingagenq•for the perform-
ance of the work for which this permit Is issued (Sec. 3097, Cie. C.)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
Lender'sName
Lender'sAddtero
I cedlfythatl have mad thbappliationand slatethatthe above Information
brorrea.Iagree tocomply with all cityand county ordinances and slate laws
MECHANICAL FEE
PEES PAID:
relating tobuilding cmutrunlon, and hereby authmies representatives of this
aty to enter upon theabove-meinWrud property for inspection purposes.
(We) agree to save, Indemnify an d keep harmiea the City of Cupertino
ALTERORADDTOMECH.
Date Reeei to
P
SUBTOTAL'
against Babi@led,judgments, costasndexpemea which may lnanywayaceme
"alpetI Id Ci equence rhe graining dthle permit.
DDate`
AIR HANDLING UNIT(TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000CEM)
CONSTRUCTION TAX
Signature of ppllcant ontractor
HAZARDOUS MATE DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will thisppBrant or future building cvpant store or handle hazardous
materialefined by the Cupertino Municipal Code, Chapter 9.1 Z and the
IiraRh sad Safety Code Section 25532(a)7
RYro No
Date Ree IN
TOTAL:
HEATING UNIT (OVER 100,01) BTUI
VENTILATION rAN(SINGLE RFSID)
ISSUANCE DATE
�+ p
P pp B D
lllthe xppVcamm. mmre ildingo pantuwequipmentordevices
which emit haz rebus air contaminants as defined by the Bay Area Air
Quality Management District?
Ys ❑❑Na
haveread a Nous m of
BORER -COMP OHP OR 100,0110 BTU)
BOILER-COMP(OVER 11),01) BTU)
the Callfomla Heath
Health Code,
ode, edtonsrequirements05,25533 and 25534.
and75534. [
NEW RESIDENHAL MECFi, SQ.FT.
he ESafety
not currently a t
undthat ifton notify the..pu Ilding wes of t enxiulyhavea tenant, that Rbmy
responsibilitysncnfaCerteomeofOccriserequircmentawhlchrrvrstbecoot
prior to issuance cats Certificate of Occvpanry.
®1T 29 1991
ISSUEDCI C1.T .
Owner or authodud agent Date
TOTAL:
OFFICE COPY