22145 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building Address: ..
z1 2ys 221.45
Trw-FaIT ams: l q : A A
/.3ri
-2fS /G 1 CITY OF CUPERTINO-BUILDING-DIVISION
;ZOjhora N. : 'j/2 U)
No: APPLICATION /'PERMIT
Architect/Engin r. J Z} l l
�l'etl_ILc!e AV1 3/ �� BLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Lic.No: '
i' f" i. - ,,BVILDING,PERMI INFO '
- �p'[4`; + t B�:HCTRIC�PERMIT I" .,' i �BC
Address: S 3 ,/)644_5 ,(dtPS pat PFRX9TISSUANCE
LICENSED CONTRACTOR'S DECLARATION ❑ D
I hereby affliyrfmtthyaatt Iaajemhcensed under provisions of Chapter9(comment. APPLIANCES-RESIDENTIAL JOB DGSCRB'TION
ftgwLlcenlseC salol YV•�,ICNn3o;tuel�snd ProfcaelonsCode,and my fl � t
lim..iis lyn,fu o fact. 3J ZZ 77 PANELS ..y�.,r�._}•,1
Date �- n%_Cmmxc1or •\
ARCHITECT'S DECLARATION 201,10DOAMPS
N Zp : I understand my plass.hall be used as public records. OVER 1000 AMPS - SQ,IT,FIAOR AREA $/SQ.FT.-
E IZ(Cj -Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCRCIRT/MISC
xemptfrom the Contredorb License law far the
7 hereby a(flrmthatiam e
p q❑ following reason.(Section 70)1.5,Business and Pmfesslons Code:Any city or
FZI"'� county which requireaa pemdl toconutrugalter,improve,demolbh,orrepalr
TEMP.METER OR POLE INST.
0��
qa anyetrodure pdorto lb Lssuance,alaa requlmatheappllant for such pertNt to
€5 i� V -file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
'y
OwE. Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi-
H�O:1 slon3 ofthe Business and Professions Code)orthat leis exempt themfromand SWIMMING POOL ELECTRIC VALUATION
f3 0....7777 the basis for the alleged exemption. Any violation of Section 70315 by any 0[J7LE.I.SSLVI•fCF1FSE%ilIRES u
applicant fora permit subjects the applicant to a civil penalty of nor room than
BLj I,as
dder a.ofth500). NEW RESIDENTIAL ELFGIR SQ,IT, - STORIES TYPE CONSTRUCTION
000 �n m I,as owner of the property;or my employees with wags as thele sok
compensation,willdothe B..iaa..workandio atrvdureh not intended oroffered fol
O sale(Sec 7014,to abiewandf property
Code:The Coniraowes thretue Law
does not apply to an owner of Property who builds or ees,w ided tis t and ,OCC.GROUP RES UNITS
whodoemontsa ork himtendedhrough hleowne.If,ho ever,thebuil5tauch -M,
improvement 13soldre tintendneyear fcompered nmle.the however, flder ill g orhave TOTA C..V .
Improvement beold wlthlnoneyearofcomplMlon,the owner-bu0derwlll Esus 1
tIIc�+Nen of mvin that he did not build or improve for purpose ,
P 8 exclusively p g wi I QTY. ', PLUMBING PERMIT' `FCC
LI L as owner of the property,am.7KBusi Business
and contracting with licensed H.00DTDNE APN
-
contractors to construct the project(See.70K Businev end Professbw Code: PFRMRISSUANCE
The Cmdrudors License Law does not apply to an owner of property who ALTER-DRAIN A VENT-WATER(EA)
-
Wilds or Improves thereon, and who contracts for such ptojede with a
gqIlIll!�Iador( ec,a)licensed pursuanttothe Contractor's License Law. 'FEE SUMMARY
r
Mori i exempt under SB 4c P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner - •Dale RECEIPT N
WORKMAN COMPENSATION DECLARATION FIX711RES PER SCHOOL TAX Y_ N—
hereby affirm that 1 have a cert firs
.of consent to eel(dnaure,ora RECEIPT N
adiflcab of Worken'Comperuation lruunnreora redllkd copythemof(Sec. GAS�EA.SYSTEM-IINCAOUILETB
PARRETT:. Y N
3800,lab CJ _ -
Policy N - - RECEITT N
Cam an GAS-EA.SYSTEM-OVER 4(EA)
� Y B UIL DING DI VIS ION FEES
Certlfiad copy is heed with he city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertUed copybflhd will the city inspection division. ,
CERTIFICATE OFLXEMPFION FROM WORKERS' GREASE TRAPAID
COMPENSATION INSURANCB SEWER-SANITARY-STORM EA 200PI. D21C RCCCI [#
U
(Thiess on need not be complMed if the permit b(or one hundred dollars
($103)or lmdifyth work WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
/certify eman on any Examen In any unner ad as to cern pesubjeelt is issued, —
I shall not employ any person In any manner eq as to become aubfect to the WATERSYSTEM/TREATING -
Wopkcrs'Compensation Laws of California,Date PAID
z'2 Applicant
Z 0 NX)TICETO APPLICANT.If,alar making thb Cedlflale of Exemption,you NEW RESIDENTIAL IPLMB. SQFT. Date Reeei t#
should become sub ect to the Workers'Comperaatfon provlshes,of the Labor TOTAL:
•CC — Code,you'must fos p
dhwtth comply withauch provisions orthiermit shallbe N
j deemed revoked. ELL
(L m
G CONSTRUCTION LENDING AGENCY SEISMIC FEE'
1 hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
(� ZO anaofthewormkforwhlchthbpermitlsbsued(Sec.30W,Civ.C.) TOTAL' PLUMBING FEE _
/mdse's Name -
LL'I- I.end&xAddnc. QTY, MECHANICA&PERMI'T "FEE ' MECHANICAL FEE
O W IudltythaG haveread thb appetition and patethat theabove Information
IL iscorrectlagreetacomplywlth all city and county ordinances and pate laws PERMIT ISSUANCE' FEE—PAID:
>. relating to building construction,and hereby authorize representatives ofthls -
Zcity to enter upon the above-mentioned properly,for inspection purposes. ALTIRORADDTOMECH.
— Mr)agree to save,Indo Ify d p harmless the City of Cu pertlno Date•, Recei t#
aga WtBab' e,Judg t,cop d pensee which may In anyway sews AIR HANDLING UNIT QO 10, CFM)
SUBTOTAL:
aga Wee Ityln en f1 grant Ing of this it
/` J""a yu, / AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Sign re of Appllant/ oniractor ' Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID: '
71
HAZARDOUS MATERIALS DISCLOSURE
Z)the appllant or future building occupant atom or handle hazardous HEATING UNIT(10 100,0f)O BTUE
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date RCCEI t#
I lealth and Safety Code Section 25532(a)I HEATING UNIT(OVER iEXE0W BTU) TOTAL:
F1 Yea ri No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE J ANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air '
� S�afhty Management Dis(dd7 - BOILER-COMP DEEP OR 100,000 BTU) ,�Ilry.�al$lpI
I I Yes �No 'WA P }
havereadthe bazar fet materials iquiremenhunden Chapter 6.95 of 'BWLE&COMP(OVE2100,000 BTU) � !
the Gltandt atifth A building
Code, otcurontlyh tia tenant,
thati I - g
understand thatiltify the occupant
note mquiyhavea tenant that Ines my NEW R6IDFNITALMCCH. SQ.FT
responsibilityce notifytheicte of oftherequirementswhich most he met �Gi'Rflg/
prior to Issuance of Certiflate o(Ocapanry, '
-0 rerorauthoorad agent Data -
P _ TOTAL: ISSUED B :
Y
OFFICE COPY