22287 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address:
22287
s ��,
caner; `VS, _ 3e:
qejf6g
CITY OF CUPER7IN0.BUILDING DIVISION
NoCoo- mp� � r
CS ' PERMIT,APPLICATION /
Cows—, 8k BUILDINC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY • CONTROL p
Architect/Engineer, -Lk.No:
QTr •ELECTRIC PERMIT FEE B[JII;DINGPERM71?INFO
Address - PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hemsed under provisions of Chapter9(commenc. APPLIANCES-RESIDENTIAL JOB DFSCRR'TION
togwith Section 7000)ofDlvlsim3afthe Businessand Pmfess msCode,and my r,. .
itcense Is in full fo and effect, PANELS - .rt1 • 1
LlcenseC ® LICX-c 1 L.Y !
Dale Contractor �.4IM TO 200AMPS
ARCHITECTS DECLARATION X11-1000 AMPS
Orel (understand myplamshallbe usedespubhererords. OVER1000AMPS ARS
qq�++ O
}i Licensed Pmfeasbnl _ SIGNSELECTRICAL 7pcQ'/
GG<(kqw OWNERexULDER DECLARATION
SPECIAL CR2CUT/MIST TE
f' owingLp
reason.
Sectiofluit 7031 Z,exempt ossa d Professions Code;
Uw tort he
Zfollowingreason.(Section7031$Businessand Pimpmona Code:Anycity or
mplr
t.� countywhlch requlresa permittocbntrucL alteq improve,tlemolbh,orrepair TEMP.MECEROR POLE(NST.
anys[mcture priorto its iswance,alsorequlreathe appliantfor such ParMtm /
rNG file a signed statement that he Is licensed pursuant to the provisions of the TOWER DEVICES
Ott Contractors License Law(Chapter 9(commencing with Section 7000)of Divl-
�0� sion3otthe Boslnessand Profession Code)orthatheis..mptthenfromand SWIMMING POOL ELECTRIC' VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES 1 ()(�
applicant fora permit subjects the applicant to a civil penalty of not rnorethan
five hundred dollars($SM. NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole �'FT' STORIES TYPE CONSTRUCTION
compeneation,will do the work and the structure Is not Intended or offend for
sale(Sec.7044,Business and Profession Code:The Contractors License Law
�Q does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroftered forsale.If,however,the building or TOTAL: l
improvement issold withinoneyearofcompletiogtheowner-builderwBl have
turdes of previngthat he did not build or Improve for purpose ofske.) (7('y�;';t PLUMBING PERMIT ��'FEE, FhOOD ZONE APN
In L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profession Code:
The Contractor;License Law does not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p(ujeRs with a ALTER-DRAIN&VENT-WATER MA)
codactor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
I_j I am exempt under Sec, B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date
DRAINS FLOOR CON
T3.AREA,COS. SANITARY Y_ N_
RECEIPT B
WORKMAN I have a COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N
❑i hereby affirm that I have o certificate of ao ftif to self-insurethemoi ora RECD,p
3800,abofWorkers CompenationlnuranreoraremFled ropy thereof(Sec. GA PA.SY9TEM.1 WC40UTLM S PARK FEE Y N
3800,Lab C.)
. Policy# GAS F.A.SYSTEM-OVRR4(EA) REC=#
Com any - BUI LDINC DIVISION FF IS
Certified copy is hereby thecity
furnished.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed withh dry Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARYS10RM FA 200FT xs-6,ttes Rerni f# dl�
Rhlssectlan need not be completed If the permlt la foron;hundred dollars _
($]00)orlythat Nthe performance of thework torwhlch this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person In any manner so n t come�eubject to the WATER SYSTEM/TREATING '
Workera Comp tion weo Date 4f�fr'/q, PAID
O Z Applicant T:If, Ky��a��ei NEWRESIDENTIALPLMB. SQXT. Date Recei t#
z O NOTICET APPLIC [seher rrdIing this CertRlate of Exemption,you
should become subject to the Workers'Compensation provision of the Labor TOTAL:
N Code,you must forthwith comply with such provision or this permit shall be
W j deemed revoked, - BUILDING l
np
0. c CONSTRUCTION LENDING AGENCY SEISMIC FEE $
I hereby affirmthat there Is a mntruction lending agency for the perform ELECTRIC EEE
7 ZaraceoftheworkforwhichthispermltbL .s d(Sec.3097,Civ.C.) TOTAL:
V O Lender.Nam; PLUMBING FEE
LL'I— Lender.Addnsa - 'QTY. 114ECHANICAL EERivIIT -,,FEE ,. MECHANICAL FEE
O W lreditythatlhavenadthlaappBationand Aatethatthc abovelnforeration
1 Is correct.Iagree to comply with all city and county ordinances and state laws PERMU ISSUANCE FEES PAID:
j. W relating to building construction,and hereby authorize representatives of this -
I"' Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
z (We)agree to save,indemnify an d keep harmless the City of Cupertino
against llabiliics,judgments,mks and expenses which may in anyway same AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalne d C in con en f the granting of this permit.
�. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gature of Appiant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: t
❑Yes No
Will the applicant Xture building occupant use equipment or d evince VENDLATIONFAN(SINGLE RESID) ISS CPj.DA'T'E
which emit hazardous air contaminants as defined by the Bay Area Air sa9�
silty Management District? BOILER-COMP QHP OR 100,01M BTU
I
II YBiYes ®No 4J
have read thebaza(dous materials requirements under Chapter 6.95 of BOILFR-COMP(OVER lq),000 BTU) ��
the California Health&Safety Code,Section 25505,25533and 25534.1 'yF•
understand that lithe building does not currently have a tenant,that itis my NEW RESIDENTIAL MEIN. SQ.FT. ase
responsibility to notify the occupant of the requirements which must be met
P6.r to' uance faCe III teofOmpancy.OIV
9 �p,� s�•s `
neer or authorized agenic Al Data TOTAL: ISSUED
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address:
22287
s ��,
caner; `VS, _ 3e:
qejf6g
CITY OF CUPER7IN0.BUILDING DIVISION
NoCoo- mp� � r
CS ' PERMIT,APPLICATION /
Cows—, 8k BUILDINC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY • CONTROL p
Architect/Engineer, -Lk.No:
QTr •ELECTRIC PERMIT FEE B[JII;DINGPERM71?INFO
Address - PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hemsed under provisions of Chapter9(commenc. APPLIANCES-RESIDENTIAL JOB DFSCRR'TION
togwith Section 7000)ofDlvlsim3afthe Businessand Pmfess msCode,and my r,. .
itcense Is in full fo and effect, PANELS - .rt1 • 1
LlcenseC ® LICX-c 1 L.Y !
Dale Contractor �.4IM TO 200AMPS
ARCHITECTS DECLARATION X11-1000 AMPS
Orel (understand myplamshallbe usedespubhererords. OVER1000AMPS ARS
qq�++ O
}i Licensed Pmfeasbnl _ SIGNSELECTRICAL 7pcQ'/
GG<(kqw OWNERexULDER DECLARATION
SPECIAL CR2CUT/MIST TE
f' owingLp
reason.
Sectiofluit 7031 Z,exempt ossa d Professions Code;
Uw tort he
Zfollowingreason.(Section7031$Businessand Pimpmona Code:Anycity or
mplr
t.� countywhlch requlresa permittocbntrucL alteq improve,tlemolbh,orrepair TEMP.MECEROR POLE(NST.
anys[mcture priorto its iswance,alsorequlreathe appliantfor such ParMtm /
rNG file a signed statement that he Is licensed pursuant to the provisions of the TOWER DEVICES
Ott Contractors License Law(Chapter 9(commencing with Section 7000)of Divl-
�0� sion3otthe Boslnessand Profession Code)orthatheis..mptthenfromand SWIMMING POOL ELECTRIC' VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES 1 ()(�
applicant fora permit subjects the applicant to a civil penalty of not rnorethan
five hundred dollars($SM. NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole �'FT' STORIES TYPE CONSTRUCTION
compeneation,will do the work and the structure Is not Intended or offend for
sale(Sec.7044,Business and Profession Code:The Contractors License Law
�Q does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroftered forsale.If,however,the building or TOTAL: l
improvement issold withinoneyearofcompletiogtheowner-builderwBl have
turdes of previngthat he did not build or Improve for purpose ofske.) (7('y�;';t PLUMBING PERMIT ��'FEE, FhOOD ZONE APN
In L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profession Code:
The Contractor;License Law does not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p(ujeRs with a ALTER-DRAIN&VENT-WATER MA)
codactor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
I_j I am exempt under Sec, B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date
DRAINS FLOOR CON
T3.AREA,COS. SANITARY Y_ N_
RECEIPT B
WORKMAN I have a COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N
❑i hereby affirm that I have o certificate of ao ftif to self-insurethemoi ora RECD,p
3800,abofWorkers CompenationlnuranreoraremFled ropy thereof(Sec. GA PA.SY9TEM.1 WC40UTLM S PARK FEE Y N
3800,Lab C.)
. Policy# GAS F.A.SYSTEM-OVRR4(EA) REC=#
Com any - BUI LDINC DIVISION FF IS
Certified copy is hereby thecity
furnished.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed withh dry Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARYS10RM FA 200FT xs-6,ttes Rerni f# dl�
Rhlssectlan need not be completed If the permlt la foron;hundred dollars _
($]00)orlythat Nthe performance of thework torwhlch this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person In any manner so n t come�eubject to the WATER SYSTEM/TREATING '
Workera Comp tion weo Date 4f�fr'/q, PAID
O Z Applicant T:If, Ky��a��ei NEWRESIDENTIALPLMB. SQXT. Date Recei t#
z O NOTICET APPLIC [seher rrdIing this CertRlate of Exemption,you
should become subject to the Workers'Compensation provision of the Labor TOTAL:
N Code,you must forthwith comply with such provision or this permit shall be
W j deemed revoked, - BUILDING l
np
0. c CONSTRUCTION LENDING AGENCY SEISMIC FEE $
I hereby affirmthat there Is a mntruction lending agency for the perform ELECTRIC EEE
7 ZaraceoftheworkforwhichthispermltbL .s d(Sec.3097,Civ.C.) TOTAL:
V O Lender.Nam; PLUMBING FEE
LL'I— Lender.Addnsa - 'QTY. 114ECHANICAL EERivIIT -,,FEE ,. MECHANICAL FEE
O W lreditythatlhavenadthlaappBationand Aatethatthc abovelnforeration
1 Is correct.Iagree to comply with all city and county ordinances and state laws PERMU ISSUANCE FEES PAID:
j. W relating to building construction,and hereby authorize representatives of this -
I"' Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
z (We)agree to save,indemnify an d keep harmless the City of Cupertino
against llabiliics,judgments,mks and expenses which may in anyway same AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalne d C in con en f the granting of this permit.
�. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gature of Appiant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: t
❑Yes No
Will the applicant Xture building occupant use equipment or d evince VENDLATIONFAN(SINGLE RESID) ISS CPj.DA'T'E
which emit hazardous air contaminants as defined by the Bay Area Air sa9�
silty Management District? BOILER-COMP QHP OR 100,01M BTU
I
II YBiYes ®No 4J
have read thebaza(dous materials requirements under Chapter 6.95 of BOILFR-COMP(OVER lq),000 BTU) ��
the California Health&Safety Code,Section 25505,25533and 25534.1 'yF•
understand that lithe building does not currently have a tenant,that itis my NEW RESIDENTIAL MEIN. SQ.FT. ase
responsibility to notify the occupant of the requirements which must be met
P6.r to' uance faCe III teofOmpancy.OIV
9 �p,� s�•s `
neer or authorized agenic Al Data TOTAL: ISSUED
OFFICE COPY