22300APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification
Building Address: —D--,1872^ S �r� - , (.7 t,
`1NI-xAl�l V��./IVI �J
PERMITNO.
22300
caner 171,51 ppyy..aa '� A—C--J one:
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CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
p
Contractors N.me: Lic. No:
BUILDING-ELECTRICAUPLUMBING-MECHANICAL
CATDCORY
CONTWR (p O
' Architect/Engineer. Lk. No:
QTY ELECTR/CPERMITFEE
BUILDING PERMIT INFO
dre
Adss
PENMITISSUANCE
❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyetl amlicensed order provisions of Chapter 9(mmmenc-
ing with Sedom7000.l3oftheBusiness ProeWonaCode and my
It...ls1.(ullf..andff.d.
AIPLANCESRESIDENTIAL
^ J -O -.B D�FCRBaa]•ION
�—
PANELS
Licence Class Lic.p
Date C.nt.dor
— UP TO 200 ANU
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
OVER 1000 AMPS
SQ.Vf.FLOORARFA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyaffirmthat I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/1,415C
TEMP. METER OR POLE INST.
following reason.(Section7011S, Busineasand Professions Code: Any city or
countywhich rcqulms a permit to mmtmd, alter, impmve, dens W h, or repair
anystruaure priorto its Issuance, also requlresthe applicant fornuch permitlo
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
alon3 ofthe Business and Profemloro Code) orthat he Is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant lora permit subjects the applicant to a civil penalty of nor more than
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
l Q fj
MV
OUTLETSSWITCI;FSFIXNRES
NEW RESIDENTIAL ELECTR FT.
five hundred dollars ($500D.
r-1 1. as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the stmcture b not intended or offered for
sale (Sec 7014, Business and Profesdmu Code: The Contractors License Law
docs nat.pply m so owner of property who build.., improves thereon,and
who doessuchwork himself orthrough hisown employees, provided that such
OCC.GROUP
RES. UNITS
improvement are not intended oroffered forsale. If, however, Ihebuilding or
Improvement u..Id withinoneyearofcompietion,the owner-bullderwill have
TOTAL:
t1iLtlarden of proving that he did not build or Improve for purpose ofsale.).
LJ L as owner of the property, am exclusively =trading with licensed
contractors to construct the project (Sec. 7644, Business and Prdesaimni Code:
OTY, PLUMBING PERMIT FEE
PERMRISBUANCE
FLOOD ZONE
APN
The Contractor's License Law does net apply to an owner of property who
Wild. or Imp. thereon, and who contracts for such plojects with a
cc ,�B(Tador(s) licensed pursuant to the Contractor's License Law.
LJI am exempt under Sec B A P C for thin reauns
ALTER -DRAIN &VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTVRF.S PER TRAP
SANITARY Y N_
RECEIPT N
Owner Date
WORKMANCOMPENSATIONDECIARATION ❑
I hereby affirm that I have • comflcate of consent to self -insure,
SCI;OOL TA% Y N
or
cent(iateofWorken'C.mpematl=I] ranmoramAifledmpythemof(See.
3500, Lab C.)
RECENT N
GAS EA. OUTLETS
PARKFEE Y_ N
Policy p
RECEIPT N
Com any
GAS G. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FE ES
copy 6tat herebyturne cityad.
Certified ropy t filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhiesectlon need not be completed lithe permit ls for orae hundred dollars
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
/"
r_era
PAID_ n praLQ
Recel t# I7"'a
Date - 1,
GREASE TRAP _
SEWER -SANITARY -STORM EA. 200PT.
($1I ormles..)
cent that o any pehe rson In any number so a to this pesubj cissued,
I
L shall not employ any person In any manner at a to become subject to the
Workers'Compensation Gwe ofCalifornia. Data.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N—
—
PAID
WATER SYS /TREATING
ApplicaNOTICE
OTICE
NOTICEco MPLICAtot a after makingfhb .t I..lateis Exempous oft the Lab or
should become subject to the Workers' such pruason prothis permit hall
Code, you mart forthwith comply with such provisions or this penNt shall be
deemed revoked.
Date Recei
NEW RESIDENTIAL PLMB. SQFT.
TAt
BUILDING
TOTAL:
SEISMIC FE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
IherebyafOrmthat them b a construction lending agency for the perform.
an. of the work for which this permit b issued (Sec. 3097, Civ. CJ
Lender. Name
Lender's Address
I mnifythat l have read this application and statethat theabove Information
6 mane.] agree to comply with all city and county.rdlnances and state laws
QTY. MECHANICAL PERMIT FEE
-
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FBG
FEES PQ
relating to building construction, and hereby authorize repereematives of thin
J�
city to enter upon the above-mentioned property for Wpeni.n purposes.
Me) agree to save, indentdty an d keep harmless the City of Cu penins
against llabilltles,judgment, mks and expenses which may In any way accrue
against said City In consequence of the granting of this permit.
ALTO;ORADDTOMECH.
AIR HANDLING UNIT DO 10,000 CFM)
Date Re ei t#
P
SUBT TAU
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TA
Sigrutureof Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building ocmpant storeor handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 91Z and the
Date Ree t#
HEATING UNIT (OVER 100,000 BTU)
TOT s
Heahhand Safety Cade Secti.n25532fa)I
❑ Yes NN.
VFNfILATION PAN (SINGLE RESID)
ISSUANCE DATE
AMM
AQP
Will the applicant orfumrebullding occupant use equipment ordeviccs
which north hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yea ❑❑ No
have read the haz9Nornaterials requirement under Chapter 6.95 of
BOILER -CAMP Ohm OR 100,0(0 BTU)
BOILER-COMP(OVER 100,000 BTU
the California ITralth k Safety Code, Sections 25505,25533 and MU. 1
understand that lithe building does not comenlly have a tenant, that It is my.
responsibility to notify the occupant of the requirement which must be met
y y
AUG,Q.Fr. U tF 47
NEW RESIDENTIAL MECH.
prior to issuance of a Certificate of Occupancy.
asses _
ut of Cd
ISSUEDBY,
Owner or authorlad agent Date
TOTAL: I
OFFICE COPY