22049 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT PEN ONLY
Building Project Identification r PERMIT NO.
Building Address: - -
5ov3�5Z �� -22049
weer. ams: - - ane.
(-�(.}$ZQ.y�►-( V '� L,pW _ CITY OF CUPERTINO-BUILDING DIVISION . t4--q
11
c°nlraMoia Name: fQa� LI=.No: 'APPLICATION /PERMIT
IT
n` �C —°�°�'• BUILDINGELECTRICAL-PLUMRINGMECIIAMCAL - CATEGORY CONTBOiyNL�O
Architect/Engineer. ,Lic.N. 10 K
ELECTRIC PERMIT
�,,BUILDINB GI�
PE
RMIT,INFO-I,
Address: t
PERMTISSIANCE
LICENSED CONTRACTOR'S DECLARATION
Ihercby afrm that la [cmsedunder Pwidons o(Cha ergmAPPLIANCESRFSIDENIAL
- RNI30N -
IngweI,In bitto.afdiW,lon3otthe Businesaandl'rofe„IomCode,andm d�•-wl OE`gC� /rir_g5r
license Is In full force and MfeM. - PANELS rum(' ,,I \ 1 a"/l]'9-fes' a J�'^
License Class 'Lie.p • .�`. 15__ p :
Date Contractor
ARCHITECTS DECLARATION - 201-1000AMPS
q9
0 Z I understand my pl oa,hall be used as public records OVER 1000 AMPS. SQ.FT.FLOOR AREA $/SQ.FT.
q��++ SIGNS ELECTRICAL 1�
Fi�(Gj Licensed Pro(c.lonal" '' - - �BOg�S L�
<<ccV1 OWNER-BUILDER DECLARATION ^ ,
�n 6�S SPECIAL CEtCU1T/MISC - /
a owingrme.(hallam3",Blro ossa Contractor's License lass for the '-'zoo; � I�tO
pp following reason.(Section 70315,Business and Profes,loris Code:Any city or
O 2.1- TEMP.METER OR POLE INST. -
rr,� muntycture requlresa permittommrequirlter,ImprovGdemoBeh,ororsuch notto
qg any at rudurepte.conlahat he It lice sed pursuant t the provisions
to POWERDEVICES
the a signed rtatement that he la IlmneM pursuant to the provkione of the -
g� Contractors License Law(Chapter 9(comerencingwith Sa000n7000)of Divi- SWIMMING IDOL ELECTRIC -
Mo.3ofthe lhodese and PtofemionsCode)orthat he is exempt therefromand VALUATION
_
the baLLs lot Ile alleged exemption. Any violation of Section 7MIS by any DO OVfLE.ISSW[.fCFICSFI%.IVRES q va Q 21 t y `�] ��
'applicant fora permitsubjects the applicant to a civil penalty a net morethan a p�t
five hundred della.(8500).
t7RC"v NEWRLSIDENTIAL ELECTR SQ.FI'. STORIES ECONSTRUCTION
LLilil �n ❑e as saowmr of the prop",a or my employees with wage,cue their sok p L�
< cI.(Se. 0Kflont,will dothe
...d Prfesel. e[odureheis Contactor.ntended or...Law - (\ q �, 3 0 �1 N
❑ sale(Sec. pply to
nownerf property
Code:The or impoee, he. law J
3$
does not apply to an owner orth p g y who b empl yeas p e ided t the.,and
ch }OCC CRO .UNITS
whodoessuesare Ii ntededoroughhhowne.If,
thebuhatsucn r. f�J
Improvementissold ithinded earofcomplroffered tiomth,hemer-b deer ilingw TOTAL: .�• L
improvementb,old within oneycaro(complMlon,the owner-bullderwlll have -
enofprovingthat he did not build orimprove for purpose ofsale.). QTY�1�3" "11,PCUMBING PERMIT'?, ;1'1' �,t FLOG ZONE' PN
a,owner of the property,am exclusively contract....with Ilcemed PERMIT ISSUANCE
tractare to construct the project(Sec.7054,Business and Professions Code: - N
Contractor's License Law doea out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) ,a�{h -
Wilds or Improves thermM -
., and who contracts for such ploje
s"with a
t,Iracmr(s)Bcenaed pursuant o the Contractors License Law. - - i"� "FEESUMMARY
LJ am exempt under Sem - B&P C'for this ream. BACK FLOW PROTECT.DEVICE OUTS I DE FEES
DRAINSLO
FORROOp AA,COND.RE .SANITARY - Y - N
Owner Date RECEET# '
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP.. SCHOOLTAX Y N
01 hereby affirm that I have a certiflcete of consent to selMnsure,or a RECEIPT M
cehifimteofWorkers'Comper timlruu.nreoiamrtifkdmpythe.af(Scc, '•
3800,lab C.) GAS F.A.SYSTEM-1 WC.40ITILETS PARK FEE .Y N.
Policy# - - RECEIPT
Com any GAS EA.SYSTEM-OVER4(EA) - �CXJ BUILDING DIVISION FEES
Certified copy is heed with thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Q
Certified copy b hexa y fu led dry inspection divlslon.
-CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP ' . PAID
COMPENSATION INSURANCE - -
Ghbsecti°n need not becompleted lfthe permit Isforonehundred dollar SEWER-SANITARY-STORM EA.200177. Date Recei [# a'T�ga 1.
(81110)or lees.) ATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
I certifythat in the performanceo(the work forwhich this permit is ksued, l�
I shall not employ any person In any manner so m to become subject to the
Workers'Compenestlon Laws of California. Date - WATER SYSTEM/TREATING PAID T-ys
O Z Applicant ti - NEWRESIDENTIALPLMB. SQ.FT. Daft Recei t#
Z 0 NOTICE Tome,wb dtot:e rel making this Certificate ss Exemption,you I[1t
.F CMcshouWcome surthwit co ply wit Comproveonprovblmuoflhe Labor - TOTAL: •-t,
W Code,you rwst forthwith comply withsuchprovislov orthB pemdt shall he _ G _
> deemed revoked. - UILDN 'E
.L C CONSTRUCTION LENDING AGENCY + ` - SEISMIC PEE
I hereby affirmtha them k a construction lending agency for the perform- SEISM( IFEEE - s
� Z -once of the worktor which this permit is issued(Sec.30W,Civ.C.) TOTAL:
02 I..derb Name - . ,. . t - PLUMBING FEE 1
LL F- Lender's Addre,. - QTY: ( 1 IVTECHAN_ IC_AC PERMIT", , ;',.FEE' MECHANICAL FEE
OW .I cedifythatI have read thisappllcathmrand Mate thatthe above Information ^^•�a
a is coirect.I agree tocomply with all city and musty ordinances and state laws ( ' PERMITISSUANCE 144�LP FEES PAID: .
N relating to building construction,and hereby authorize mpecaentstlLesof this - ,
f- Z Mly toenterupon the cubo mentioned prop, for WpeMlon Purposes. ALTER OR ADD1U MECH. l� Date Receipt#
lWe)agree to cave, demnity a keep en the City of Cupe Ina
against llabllitlea,' d menta, Ms which may In an ay ecru, AIRIfANDLINC UNIT TTO10,000CFM) SUBTOTAL:
.gal aald Cl n n tr(g of this permit.
allS AIR HANDLING UNIT(OVER IBW0CFM) CONSTRUCTION TAX'''
groT p 1 t/Co Mor to E%HAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
AZARDOUS MA TERIALSDISCLOSURF. i1
.Will the appI ant or future building omupanl store or handle hazardous a� HEATING UMT(TOIW,000 BTU). lY ,Date Receipt#
material as deft edby the Cupertino Municipal Code,Chapter 9.12,and the -
'Health and Safety Code Section 8532(.)7 - HEATING UNIT(OVER 100,000 BTU) TDTAL:� a
F-1Yenr]No _
Will the applicant or future building occupant use equipment or devices `3 VENTILATION FAN(SINGLE RESID) 15 ISSUANCE DATE
which emit haeardous alrearlmlmntsas defined bythe Bay Area Air I ®AOCV1 -
QualityManagement Distrid? BOR.RR-COMP PIN OR 100,11(1(1 BTU) iI
4 Yea n No
have read the hazer ousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,!%)!1 BTU)the
9 s�YGa�
the Ca liforela Health&Safety Code,Sections 8505,8533 and 25534. I IY13_7-.sTb
understa not that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT p
responsibility to notify the occupant of the mqumments which must be mot
prior to Issuance o(a Certificate of Occupancy. -
- s01 cupitilm
'Owner or authorised agent Date -
TOTAL; S ( ISSUEDBY -#•-
OFFICE COPY "