22312 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PMW'r NO.
Building Add.
lgadsi SSI, dplP 7 �. eupc-alNo (q Id, 22312
one: AI1FLF�AInJN bUbMIliAL -
�-�^� j QTYOFCUPERTINO-BUILDINGDIVISION
Co ANanta: L .No: APPLICATION / PERMIT . ^ Z
F 110 F
'
BUILDING-ELECTRICAL T-UMBING MECHAMCAI CATEGORY CONTROL pL�'f
Archit / gl ser. p Llc.No bQ
������ zapq QTY ELECTRIC S�is� r 1 ELECTRIC PERMIT •;FCE Yee 'BUILDING PERMIT INFO
s ti TOSr Q�
Address: - r PFRhITISSUANCE El El ❑ .
LICENSED CONTRACTOR'S DECLARATIONN -
.l hereby affirm that l am licensed under provisions o(Chapmr9(corvemc- APPLIANCFSRF.SIDEMIAL ]OB DESCRIPTION
Ingwlth Section 70W)ofD[Wslon3ofthe Budnessand PmtemionsC e,and my
liana lslnfuBforce and effect. PANf75 /)
Date Contractor UPT0200 NEPS
ARCHITECTS DECLARATION 201-1000 AMPS
9z I understand my plarushaBbeused as public mrorde. OVERI000AMPS SQ.FT.FLOOR AREA E/SQ.Fr.
00
rd�
Licensed ProfessionEC
al SIGNSELTRICAL +a: OWNER-BUILDER DECLARATION'
Ina SPECIALCItCNT/MISC s
-I hereby affirm that l am exempt from the Contractor's Llmnee Law for the
Q p followingreason Glim7m1.5,Badnessand Professions Code:Anydtyor zty� c.untywhich requlresapapertNtto'comtrut,alleglmprove,demolish,orrcpalr TEMP.METER OR POLE INST. -
q''°� anystructure prlorto its Issuance,also requires theappllant forsueh perMtto .
FJ r�2 +I file a signed statement that he Is licensed purauant to the provisions of the � R DEVICES .,
Q6 3 u,IContractor's License law(Chapter 9(commencing with Section 7000)of Divi-
n SWI.1 W NG POOL ELECTRIC
f•E!OS de basis fo Basinllsand exemption.Any
Ls exempt therefrom and _ _• •••� VALUATIONOD
Q 9 the bash for the alleged exemption. Any vlolatlon°(Section 7031.5 by any OUTLETS
ppr permit subjects
SWLTCHES-FIXTURES- C C7 D;O
alicant for a eit bcts the applicant a t tcivil penalty of not room than
h
$ five hundred dollars($SM. _ ^ NEW RESIDENTIAL 1: rCTR' `SQ.FT. STOy115 TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
�7a compensation,willdothe work and the structure ix not Intended or offered for -
$ 0
.1.(See.7010,Btsmate,and ProfessloreaCode:The Contractor's Uce.law
{{5$ does not apply to an ownerof property who bulldsorleeproves thereon,and CICC.GROIIIa RES.UNITSE: who doessuch work himsafrethrough his awn employees,providecithatsuch
improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement h..ld withinoneyearofmmpltiagthe°wneo-bullderwill have -
t e enofproving that he did not build orlmprove for purpose of Bale.). Q'Ty„gid, ' PLUIYIBINGPERMIT'.I t�” r3,rl'FEE^ FIADp ZDNE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ntra on to constmt the proje<(Sec.701y RusNem and Erofemlov Code: _
- The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(G) -
builds or Improves thereon, and who contracts for such p(ojecte -
with a r
tt ctor(a)licensed ursuadttothe Contractor'sLicense Law. '' - t",;'sFEE'�$UMMARY
LII am exempen t under SB&' �P C for this reason BACK FLOW PROTECT.DEVICE. s,
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner - Date RECEEPr M
WORKMAN COMPENSATION DECLARATION _
a
01 hereby affirm that I have a certificate of consent to self-Insure,ora FD(.I.IIRFS PER TRAP SCHOOL TAX Y NmftifRECEIPT#
3800,Isisb CJ .EA. -1 aofW.rkem'Comperaatloninsuranceoraartl(kd ropythereo((S.c. GASSYSTEMINCA OUTLL75 - PARK FfR Y N
3800,
Policy M GAS G.SYSrFA1-0VGR 4(E
Com any -- A) RECEIPT#
BUILDING DIVISION FF.ES
-�cedified copy is hereby Furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑ m
Cmfied copy Is filed with the city Inspection eivlaloe.
CERTiRCATE OF EXEMPTION PROM WORKERS' GRGSETRAP
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.200FT. DRIC Recei t#
(Thlssetic a need not be completed tithe Numit isforum hundred dollars _
($100)or less') WATER I-IFATFR W%VENT/ELECTR ENERGYFEE Y N
I cortlfy that in the performance of the work for which this permit is issued,
I shall not employ any person In any manner au as to become subject to the WATER SYSTFSN/TRGTIN'G PAID - '
Workers'Compensation Laws of California Date -
O Z Applicant - NEWRESIDENTIAL ELMS. SQ.FT. Date Recel W
Z O NOTICETOAPPLICAtothe If,aodads'fter ompeng sCertificate fonprovisions
oft the
'
should
you=e subject to the Worken'Comp Provisions
n por this permit s Labbe TOTAL:
or
� N Comes. meet forthwith comply with such provisioruorthlr perMtshallbe B 1 GFEE ,OD
W > deemed rooked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a 1 hereby affirm e.fthw,u] fthat Ichthhere sacordtisinst lending(Sce.3agency 7,Cle: .) perform- ELECTRIC FEE
7 Z once of the work for which thli permit bLesucd(Sex.3097,C1v.C.)
0 O Lender.Name- PLUMBING FEE
LL H Lendre.Addreas QTY. MECHANICAL�P RMIT•' "E MECHANICAL FEE
Oatlonand tatethat theabove Information
fl (scarred Isgreemc.mplywith.Udtyandmuntyordlnanceeandtatelaws PERMIT ISSUANCE FEES PAID: r —�
} relating tobulk Ing constmtlon,and hereby authorles representatives ofthls
N —f'IjI Z
city to enter upon the above-mentioned property for'Inspetlon purpose. ALTIRORADDTOMECH.
Z (We)a .e to save,IndemN(y an d keep harmless the City of Cupertino '�'+rcReceipt#
.V 11 Ilitles,j, nts,rotsandexpenenwhkhmayinanywayam a AIR HANDLING UNIT(TO I0,(D0CFM) SUBTOTAL:
a
la11 -7st City Inere of the granting of this perml�L AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX '
pp fact Comacm - Date �— EXHAUST HooD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOU ATERIALS DISCLOSURE
Will he appliont or future GM
ui Ing occupant atom orhandle haeardoas HTINGUT(TO100,030BTIn Date Receipt#
material as defined by the Cu .Municipal Code,Chaptee9.1 Z and the
Health
❑ yea and SafetyCade,-SeNloon25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant or❑future building occupant use equipment or devices - VEN11ATION FAN(SINGLE RESID) - ISSUANCE DATE ,
which eMt haaol.us air mnladert.e s ate dented by the Bay Area Air ' dGV,;y�
Quality Management District? - BOILER-COMP OHP OR 100,0(10 BTU) RaAPl�A
n
Y. n❑No a�(/`
1havereadthehairallorasnuteriabrcqulrementsunderChapter6.95°( BOILER-COMP BTU) r°T
the California Health&Safety Code,Sections 25505,25533 and 2:534.I /�s�a ""•0.a y
understand that ifthe building does not currently have a tenant,that it is my NEW RFSIDENTIALMECH. ' SQ.lT.
responsibility to notify the occupant of the requirements which must be met /I'1
prior to Issuance o(a Certificate of Occupanry. °II
Owner or author)dagent Data ISSUED B�Y:_
TOTAL:
OFFICE COPY