22703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Addres BuildingProject Identification ,. PFiI4hRT NO. '
22703
Uerneke ane: hone:
d2'I/.� 'f', .5fc�x•P� a 5L5--2321 CITY OF CUPERTINO.BUILDING DIVISION ,.•- Q� t• .
Contractor's Name: Lic.No:' APPLICATION / PERMIT
C Z GBUILDING-EZ. MCALPLUMBINC-MECHAMCAL CATEGORY - CONTROLN '
Amhltxt/Engineer. Lk.No:
r -
. '• Qry • ,t ` ." =t . 4
s BUIL•DINGPERMIT INFO
Addres , PERMITISSUANCE
❑ ❑ El
CONTRACTOR'S DECLARATION I(Zf
Thereby af(Irm thatlam Bcenaed under provlsinne o(Chapter9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlthSMlon7p0Wo(DlWdon3o(tnebuelnesaand l}a(easlonaCade,and my
license Is In full f and died. PANELS
Li
Data CU. �g =CLL
ontncmr u'A�o O
ARCHITECTS DECLARATION 201-1000 AMTS
00 I sena . d=shall be used as public mcorda. OVER IBRO AMPS SQ.hT.FLOOR AREA $/SQ.PT.
E (� Lken f fe vl _ SIGNS ELECTRICAL A L D IN
OWNER-BUILDER DECLARATION
�n Fi7 SPECIALCIRCUIT/MI5C P IJ.T E R .
7f' -./i owing af@.(Secdainexem)rtfromtheComraessio LicenseAny my or
following reason.(Section 90315,Business and Professions Code:Anysty 1,
O i:.� TEMP.METER OR POLE)NST.
F p coystmm h dortoaap anct al un uimsthea p U=tforcismulish, er ttr '
ggg O anyatroaurc prior ant hatrsnce,alcOrc d pursuant to ant provisions,
of t e POWER DEVICES y !���1�,g ��
t5 floe a signed wens eLothat het licensed pursuant it the proallora of the 7 (( 3
EOS
Contractor's users and Pr apter9(commenth(commencing he nSemptthemfmction 7000) Dlvl-
p�+ SWIMMING 1\70L ELECTRIC
the
Waistfo thealleandexempt ion. Any
V exempt therefrom and VALUATION
the baan for the alleged exemption. Any violation of Section 703 L5 by any OUTLETSSWITCHESFIXTURFS o' /
45'
applicant collars $500), ethe appgcanttoadvll penalty of not here than v
o five hundred dollen($SXIB). -
FIL as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECIR SQFF. STORIES TYPG ON'TIBUCTION
compensation,wlll dothe work.andthestm=m is ma intended or offend(or
� O sale(See 7004,Business and ProfeaslonsCode:The Contnctola Licerae Law
$ don not apply to an owner of property who Wilda or improve theman,and OCC.GROUP RES.IIIJTCS
who does such work himself orthrough his own employees,provided that such _
improvements are not intended or offered for sale.if,however,the build ing or TOTAL:
i pmvement issold within oneycarofcompletWq themener-bullderwlll have -
tryclZarden of proving that he did not build or improve for purpose ofsa .). QTY, :', `t PLUMBING'PERMITt-�'• '•:FEE >, 1.
'"S as owner of the property,am exclusively rontracting with Ilcenmd IAOD ZDNE APN
PERMRISSUANCE
contractors to mnatruct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT!WATER(PA) -
Wilda or Improve thereon,and who contracts for such pwjed.with a - .
coA,1Rl.mrns)licensed pursuant to the Condems'.Lherse Law. BAIX FLOW PROTECT.DEVICE �FEE SUMMARY
L11 am exempt under.Sec. B &P C for this masse
•
OUTSIDE F1 I S
DRAINS.}TAOR,ROOF,'ARF,A,OOND. SANITARY Y'' N_Owner DateRFGFd'T N
WOR"AN es di
SATION DECLARATION PER TRAP SCHOOL TAX �Y_ N
[] I have hereby affirm that have a aRate of consent to self-Insure,ora FIXTURES. RECEEPT N
3800,abof Worken'Compensatlonlnsurana oracedilied copy therco((Sec. GAS UA.SYSTEM-1 INCA OUTLETS PARK FIT. Y N_
Pol' 38(10,Lab CJ '
RECEI
Com env f '�1. 1` GAS PA.SYSTEM-OVEI4(EA) BUILUNCC Di VISI ON FE ES
/y/1 Lt/
Cedi(led copy hereby Tum shed.. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
' edified copy Is filed with the city inspection dlvislon.
w -
YYYY-----''" CERTIFICATE OF EXEMPTION FROM WORKERS'- GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.]OBFI'. Date Recel t#
(TNsscctbn need nor PENS TI lithe NINS RA CE one hundred dollars '
($100)mI..) WATER HEATER W%VENT/E.ECTR ENERGY FEE Y N
Icertifythat Nthe periormance of the work forwhkhthla)iermlHalsmnd,
label]not employ any person N any manner so as to become subject lathe WATIRSYSTFM/TREATING
Workers'Compensatlon laws of CaBfondat. Date PAID
Z.2 Applicant - NEW RESIDENTIAL PLMB. SQ.Fr. Date Rece1 t# s
O NOTICETO become bJe AM:R,ahermaking ompessetioniateoferempllo Lyou
should
ou= subjecttothe ply it Compensation providers p ofthe Labor TOTAL:
~ N Cone,you=at forthwith comply with such provision ortnb permit shall be
Wj deemed revoked. - BUI IN 'E• .
CONSTRUCHON LENDING AGENCY SEISMIC FEE
M0. Ih of the
work forthat ichthsamnstro tion Issued(Sec.3agency7,Civ. .) perform- ELECTRIC FEE
7Z secs o(theworkforwhkhtFbperMt is Issued(Sec.3B97,CIv.C3 � TOTAL:
U O lender's Name - - - i - PLUMBING FEE
IL H Lsndcr'aAdd.. QTY.1, „ MECHANICAL PERMIT;}' MECHANICAL PEE
OW l cedifythatl have read tntsapplicabonand statethattheabove information
C 6correct.l agree to comply with all sty and county ordinancesand state laws PERMIT ISSUANCE FEES PAID:
} relating to butllding construction,and hereby authorize representative of this
Zcity to enter upon the above-mentioned propedy for Inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to cave,Indemrdfy an d keep harmless the City of Cupertino Date Receipt#
V against llabllldes,judgments,meta and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,0 DO CFM) SUBTOTAL: -
againstsal ity lei m}�Nryuenre ahhe granting of this permit. .
/'.1 �f/v'4r--J 9 y AIR rTANDUNc UNIT(OVER lo,BBoCFM) CONSTRUCTION TAX
Signa ' (Apfiant/Contractor Dae " EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI -t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the —
Health and Safety Code Stolon 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes ff"No
Will theeppliant or future building occupant use equipment ordsvlces VFNHLATION FAN(SINGLE RESIU) ISSUANCE DATE
which emit hazardous air coma Mrunts an defined by the Bay Area Air
� Q�iality Mawgerrcnt D)t a7 BOILER-COMP PHPOR100,IXU BTU) -
4 Yes - No .
have read the hazy ousmaterialsmqulmmenbunderChapler6.95 of BOILER-COMP(OVER 100,000 BN) $�
the California Health&SafetyCode,Sections 25505,25533 and 25534. I N7
understand that lithe building does not darrently have a tenant,that it is my NEW RESIDENTIAL MSCI 1. SQ.FT 9
rnporaibiiit tonolifytneoccupant oftherequirements which mustbemet
19,gy1
prior to, "rare Ce di(Icateofoccupanry.
y,pI I
u ' F1s�to�u-
r authodd agent •.Data ISSUED BY:
TOTAL: ,
OFFICE COPY