22259 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Pwied Identification - PERMIT NO.
6u9ding Addreu: & r 2225 9
aPh
one:
r. me . ' CITY OF CUPERTINO�BUILDINGDIVISION / q
(. c a n .Name/yI C_—
Lie. . APPLICATION,/ PERMIT 6
r� QS /II R.�JL'/J - SV" BUILDING-EL MC:ALPLIMBINGMECIIAMCAL' CATEGORY - CONTROLx
Architect/Engineer. r LIe.No,
• QTY•.� ' ELECTRIC PERMIT ' . , FEE'P
.,BUILDING PERMIT INFO
.' Address: PFRMITISSUANCE. '�1 ❑ ❑ ❑
LICENSE[)CONTRACTOR'S DECLARATION 1(�}
Ihereby eftimethat lam Lemsed underprovlsionsol Chapter9(commm APPUANCr&RESIDENIIAL JOB DESCRIPTION
ingwlth Section MM)of DMsion3oflhe Buanemand ProfesaonsCode,and my
license lslnf ( ddfed. PANELS '
_ 390359
Dateg#C�lays Cmdr -
Date(��CHITECr Qp j rs{
�'I ARCHITECTS DECLARATION II 201-1000 AMPS
p�p�uua7 I understand my plans shall be used as public records. OVER 1000 AMPS TT--�� R R^ $/SQ.IT.
k IZ t Licensed Professional SIGNSELECTRICAL gJ R
«<<a{pyo OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC YYY /O�n /RR, ■■■
"" owing yafficonthatlaw eaemptfrom the dProfessio License law fort he ` f
70 O�� hollowing mason.(Semon permit
to Bustled and Professions Code:Any dep it T(MC METER ORPOLE INST: f+
r4 counlywMch requnrcsa issuartocomtrquireatheaprovgt forsueh,or repair 4.,
any structure pnorm lb hsunce,aLsa requlrestheappllant(orsuch permitto POWER DEVICES
' file a signed statement that he le licensed pursuant to the provinces of the -
Ou,� Contractors License Law(Chapter 9(mmmendng with Section 7000)of Unit- SWIMMING POOL ELECTRIC 3VALUATION 0 anon 3ofthe Buseessand Piofemlov Code)orthat he is exempt therefromand 'd
the basis for the alleged exemption. Any violation of Section 7011.5 by any _ OVILETSSwfTcHES-FIXTURES r O v
�Sapplicant fees permit subjects the applicant to a civil penalty o(net more than `
gg five hundred dollars%%DOL NEW RESIDENTIAL ELECTR FT.
i e•'Q STOW TITS CONSTRUCTION
ne as owner of the property,or my employees with wages r thele sole
7Q compensation,will do Businetheworkandthes Code:
The ure Li net
License
ed for
Law
p ale(Sec.7014,Business and[hutesslore Cade:TM Conlradof.License law
;$ does not applyto an owner of property who builds or improves thereon,and - OCC.GROUP R .UMTS
m e
who does such work hilf orthreugh hisown employees,provided that such
Improvements are not intended oroffered forsale.If,however,thebuilding or .TOTAL:
Improvement baold within oneyearofcompledon,the owner-budderwlll have - -
t rden of proving that he did not bund or improve for purpose of sale.). QTY. 't. �]eLUMIi GPERMIT'. .ctw FLOOD ZONE nPN
' LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to construct the project(Sec.7014,Business and Professions Code:
The Corral or's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER BEA)W lids or Improves thereon, and who mntads for such project,with • -
cc
,IBTador(s)licensed pursuant to the Contractor's License Law. BACJ(ETAWPROT[CT.DEVICE. FEE SUMMARY',
u I am exempt under See. B& P C for this reason
Owner - Dale - DRAINS bO
TOR ROOF,AREA,CONE. SANITARY RFOEQeT# '
WORKMAN COMPENSATION DECLARATION pp(TDRES,PER TRAP 1-71 hereby affirm that I have a cenlfiate of consent to sellAroure,ora SCITOOLTAX RECEIPT N
M00,Lab CJ
certificate of Workere'Comp..ti.n Insurance ce
ora rtilled copy thereof(Sec. CAS EA.SYSTEM-1 WC.40VTLE15 PARK FEE Y N
'
Policy If RECEIPT#
Com any GAS GA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Ceni(ied copy as hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the dty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMT'ARY-STORM FA 200Ff Date Receipt#
1111swet ed nd be complc(ed lithe permit V toronehundwddollara
($I0.)ce Ir_. WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
Irenity ti he performance ofthework farwhlch this permit is issued, ,
I shall not e y any p n in any manner n as o subject to the WATER SYSTEM/TREATING -
Worker%C n of Ca f nla.Dae 'PAID
O Z 14 it ca NEWRESIDFNTTALPLMB. JQ.FT. Date Recei I#
Z.O NOTICETOAPPLI A L ernakingtN Cenlflateot Exemption,you
ahauldbecromeaub' orkers'Compensaeon provisions of the Labor TOTAL:
jrN code,you meat forthwith comply with such provisions orthis permit shall be _ BUILDING FEE .U0
deemed revoked.
jL G CONSTRUCTION LENDING AGENCY 11 SEISMIC FEE a
0- IhercbyatOrmthat there Lsaronstmdlon lendingagency forth.penorm � TOTAL: ELECTRIC FEE
re w
M Z seoftheotk forwMchthb permit is 3097,Civ.C.) PLUMBING FEE
s B
(,) O Lenclu.Name . MECHANICALtPE2MIT FEE
Lender.Address QTY. - MECHANICAL FEE
L) Imnilythatl haveread this application and state that theabovelnforreatlon
O W iscormet.l agree to comply with all dtyand countyorelinances and statelaws PERMIT ISSUANCE FEES PAID: -
} d rehab to bullding comI of..,and herebyauthorize expresentativea'ofthis
N city ierupontheabovcreentbned property for Inspection purposes. I ALTER OR ADD TO MECH. Date Receipt#
? e agree to save,indemnify an d keep harmless the City of Cu pen lie
V age t abilities,judgments,consand expenses which may In mywayaceme AIRHANDLINGUMT(TO10,01)(I SUBTOTAL: s
aguId Cky Inco .fthegxrting:fthi It.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sgna e AVA scant o ractor Date IX1IAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
A VC MATERIALS DISCLOSURE -
Wllltheapplicantorfuture building oaupant store or handle hazardous HEATING UNIT(TO IW,WO BTU) + - Date, Recei f#'
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Socion 2S531(a)2 HFATING UMT(OVER 100,000BTU) TOTAL:
❑Yes ,(+�,No VENITILATIONFAN(SINGLERFSID)
Willtheappllantor nurn building occupant use equipment mdevices ISSUANCE DATE
which emit harardous air contaminants as defined bythe Bay Area Air - _
Quality Management DlsMd7, - BOILER-COMP QHPOR 100,000 BTL) 1,,,,%ID
sYrs o
❑N
4have readtheh..N usmrien.Ws qulrementsunder Chapter6.95of BOILEIT
R-COMP -jthn� ornialleath&SafetyCafe,SMlors75505,755JJand755J4.I ,JUNthati(thebuildnngdonnotcurmotlyh.vea treanL that it b my NEW RESIDENTIAL MF.CIiL 5Q.PTY to notify the occupant of the requirements which must be metance of Ifcitucd Occupancy.thor d c t ate .. -TOTAL: ISSUEDBY:
Vf YU�`w vCu�
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OFFICE COPY
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