22590APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building A7 cast ,
035'5' P/a res, LL) r•l-itia
PERMITNO.
22590
wrurs ante.
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION /PERMIT
BUTLDING-ELECTMCAI PLUMBING-MrCHANICAL
-O
c°^b•"°�•"• LicNo:
CATEGORY
CONTROL a
Architect/Engineer. Llo No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
SLUG FL�l PLUMB MLLH
1:1 1:1LICENSED
IN
1 PERMITISSUANCE I t�
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmmc
Ingwith Section7000)of Divleion3ofthe Bueinessand Pmfeesl°nsCode, and my
license Is In fun force and effect.
Llcansc Class Llcg
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public rmceds
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afRmnthatIamexempt ER DECLARATION
License Law for the
county which
countywhichrequires•perndtlomnstauq alter improve, Code. An city or
regtressperRf15,Bue1"eas a lid Professions Cool:h,odtyor
anystmcture pdorwits Issuance, alsorequlresthe appllcantforsuch permit to
file a signed statement that he Is licensed pursuant to the provisiors of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3lithe Busho.sand Profeashms Code) orth.t he b exempt therefrom.lid
the be to for the alleged exemption. Any violation of Section 7031.5 by any
applicant fore permit subjects the applicant to a civil penalty of not morethan
five hundred dollars($M.
❑ I, as owner of the property, or my employees with wages as their sole
compensation, wllldothe work and thestmme, is not intended or offered for
site (sec. 7044, Business and Professions Code: The C.m.d.e. License Law
does not apply to an owner of property who builds or Improves theme,and
who docs such work himself orthrough hla awn employees, provided that such
Improvements am not Intended proffered for sale, If, however, thebuilding or
improvement bsold withlnamyearofcompldioNtheowner-bullderwill have
tF4}p��leT of proving that he did not build or improve for purpose ofsale.).
�'{ as owner of the property, am exclusively contracting with licensed
mntraclom to construct the project (Sec 7044, Business and Professions Code:
The Cont cuor's License Law does not apply to an owner of property who
builds or Immot
pmvn thereon, and who ntms for such p\ojec
ts with a ctor(s) lic151ensed pursuant to the Con
radoes License Law.
am exempt under Sec. B e P C for this reason
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
1���•}
201-1000 AMPS
OVERIM AMPS
SQ. Fr. FLOOR AREA
A L E D IN
PFJ T E R
/� 4
ssa�
$/SQ. Fr.
SIGNS ELECTRICAL
SPECIAL CBiCUIT/MISC
TEMP, METER OR TOLE INST.
POWER DEVICES VAa
('��
SWIMMING POOL ELECTRIC \ 7•"�
OUTLETSSWITC1iESHXT[JRFS
VALUATION
NEW RESIDENTIAL ELECTR SQ'Fr.
STORIES
TYPE CONSTRUCTION
'
TOTAL: l
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
--
ALTER -DRAIN VENT (EN
OCC GROUP
RES. UNITS
FLOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS. FLOOR ROOF, AREA, WND.
FIXTURES PER TRAP
SANITARY Y N�
RECEIPT Y
Owner Date
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certiBate of consent to self-Inarc, or
eo(Workers'Campewtlon Wurana ora artifkd ropy thermfl5e<.
330000,,Lab mb CJ
Policy p
SCHOOL TAX Y N
RECEIrr N '
S
GAEA. SYSTEM -1 INC.4 OUTLETS
PARK FEE N
Y
RECEM
Com an Y
GAS EA.SYSTE.M-0VER!(EA)
DINC DI
BUILDING DIVISION FEES
Certified copy is hereby te
MCertifled ropy V filed withh the cityInspection division.
ty
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSUmiti f
(TFissectlon need not be completed tithe permit V (Drove hundred dollars
($1I comiress3
lartdy thatln the person ian lmanner so as tobcowhich perrNtct to smed,
Ishall not employ any person f any manner at v m become subject to [he
Workers Compensation Laws of Callfomla. Date
Applicant
shoulNOTICEio APPLICANT: aftermakingfhb atimpoicate iof somoftteLyou
Code, become subjectto the Worker•'Compensationprovisionsofthe Labor
Code, you moat forthwith comply with such provisions or this permit shall he
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyafOrmthal there is a mmbuction lending agency for the perform
onceof the work forwhich this permit is issued (Sec. 3097, Civ. CJ
fender's Name
Lender's Adamss
I artifythall haveread this appBotionand statethattheabove Infoenuticn
Isco ert. l agree to comply with all city and muntyordinanomand nate law.
relating to building mmtmetion, and hereby mthorize representatives of this
city to enter upon the abu—mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d kap harmless the City of Cupertino
aga lint liabilities, judgment, ".and expensm which may In any way..c
against said City In mnsequena of the granting of this permit.
GREASE/INDUSIRL WASTE INTERCEI'MR
PLANCHECKFEE
PAID
Date Remi t#
GREASE TRAP
SEWER-SANIITARYSIORM EA 20OFf
WATER HEATER W/VENT/ECCTR
ENERGYFEE Y N —
pplp
Date ReL'el t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQFT.
TOTAL:
N
—TOTAL:
SEISMIC FEE
ELECTRIC FEE
t
\
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date ReCCI t#
AIR HANDLING UNIT (TO 10,000 CPM)
SUBTOTAL•
AIR HANDLING UNIT (OVER I O,OW CFM)
CONSTRUCTION TAX
Slgmtu re of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplirant orfumre building occupant store or handle havardous
.tells) as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and SafetyCode Sectio,25532(a)T
Fly., M No
Will theappllcant or future bvilding occupant useequipranl ordevimro
which emit haaardous air contaminants as defined by the Bay Area All
Quality Ma mgcment District?
YesQ No
have read the haEdr°nnemdterial. requiremants under Chapter 6.95 of
the GEfomia Health h Safety Code, Sections 25SOS, 25533 and 25534. 1
understand that lithe building does not currently have. tenant, that it is my
r/onafy the ompantofthe mqulremcnhwhkhmustbemet
rlor t° Issu m offa cenirtilicate of ancy
IXHAUSTHOOD(W/DIICT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:'
y��s/
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
n
Cd��
�hGa rpt p�,.q)S
y/a1�r
c -
ISSUED044
BORER -COMP DIM OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECFI. SQ.Ff.
ocr or authommd agent Data
TOTAL:
OFFICE COPY