22348 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Priect Identification PERMIT NO.
buildingAddress:
o 2.C.2� VJ A- 22348
e A A
C, &,5s6ele_ aS-7—&r17 CITY OF CUPERTINO-BUILDING DIVISION
Com cmr'aName: Lie.No: APPLICATION / PERMIT b
• Architect/Engineer. Lice No: BUIL-DINGELBCTRICAIPLUMBINGMECHANICAL CATEGORY CONTROL M
r -{ ' " - :.BUILDING PERMIT INFO.
QTy i� ',ELECTRICPE,RMIT . ..FEE'.
Address: PERhITISSU ANCE E:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pmvklms o(Chapmr9(commere. APPLIANCES-RESIDENTIAL JOB DfisourTIO
ngwith Se on7D00)of Dlvidor3aflhe Businessard Professlom,Code,andmy �vL
license kin full force and effect PANELS
License Clss Lie# ate! VLl,.1
Date ContractorUP TO 200 ANTS
ARCHITECT`S DECLARATION 2II-1000 AMPS
mZ I understand my plans shall be used as public records. OVERIDWAMPS OOR� $/SQ.FT.
:OO L%U�j Licensed Professional SIGNS ELECTRICAL
<
OWNER-HOLDER DECLARATION $PFCIALCEiCUIT/M1SC UTE R
3 I hereby affirenthal I am exempt fromthe Contractor's License law forlhe P
following maven,(Section 7(l Business and Professions Code:My city or
muntywhlch
t• Gi!
t..� rnryloapermit tomnetruct,dler,improvemo
,delsh,orrepalr TEMP.METER OR POLE INST.
x anyatru mpdortolk Wuame,alsomqurestheapplrantforsuchper tto POWER DEVICES 1
file a signed statement that he Is licensed pursuant to the prowsiom of the
I^I�n Cnnindors License Li.(Chapter 9(commencing with Section 7000)ofDivi.
.05 sion3oftoe BusinesmdProfmio.Code)orthatheinexempiihemfmmand SWIMMING POOL ELECTRIC VALUATION
the bask for the alleged exemption. Any violation of Section 70315 by any OUTLETS—SWITCHES-FIXTURES
- � apphnnt fora permit subjects the applicant to a civil penalty of not momthan �C
-' five hundred dollars($500). STORIES TYPE CONSTRUCTfON'
' -' I,as ownero(the property, NEW RESNENTIAI,ELECTR SQ}T.
❑ p perry,or my employers with wages as their wk
mmpensaHon,wEldothewmkandthesesu mu nmmtended or offered for
F0 sale(Sec 70K Business and Pm(essimu Cade:The Contrattor•s Limwe Taw
3$ does nm apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RES.UNITS
who daesauchwark himself or through Msown employees,provided that such
impmweramk are oat intended or offered for sale.If,however,the building or TOTAL:
improvercentis within one yesrofcompletion,the owner-builderwill have I„ F,r_ *, �
the en of proving that he did not Wild or Improve for purpose ofsale.). QTy, yi'�„ya^gt4'PLUMBING PERMII`'',e•..�,'�_:,:* ; HL)OD7ANE APN
owner of the property,am exclusively mntracHng wish Ilcensed pip ISSUANCE
to commict the project(See 7011,Busmm and Pmfeabru Code:
Contractors License Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(m
builds or improves therson, and who contracts for such ptojees with a .• C'�';W t `7• 5:" i
ogpj(acim(s)homand pursuanttothe ContradmiLicenseLaw. �y ',' ;,.FEEr$uMMARY..<,,,,•,_z,,,,
U I am exempt under See B&P C for this reason BACK FLOW PROTECT.DEVICE
FFrq
DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIX'IlJRES PER TRAP SCHOOL TAX Y N
❑I herby affirm that I have a certificate of consent to self-Inco,m a RFCEI'I#
cerH(lateotWorkers CompemaHonlmunncemacertHkd mpythwmf(Sec.
380,Tab C3 GAS EA.SYSTEM-1 TNG OUTLETS PARK FEF Y N
Policy# GAS EA.SYSTEM-OVER 1(FA) RECEIPT M
Com any BUILDING DIVISION`FEES
�Certifled copy k hereby furnished.city GREASE/INDUSM WASTE INTERCEPTOR PLANCHECK FEE
❑CartNed copy k(Ikd with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIDCOMPENSATION INSURANCE SEWER-SANTTARY-STORM EA X101• Date Recei t#
(ITie lection neM rad be complded Hthe permit k Torose hundred dollare
6100)mfyth WATER HEATER W/V�/ELECTR ENERGYFEE Y N
Illnoy thatkthe dWmperson In
the weekkan so t bthiseemdtkissued,
I shell not employ any person in any manner at e to herons subject to the WATER SYSIFM/TREATING
W [ampewHon lawn of California. Date PAID
ApplicantOCENEW RESIDENTIAL PLMB. SQFf.
. ZDate Recei t#
. O NOTICEca esubjeAM:e,Cher mikirgrs'Co filo Ction previsions
oft
a you
Coded become subject to the Workers'sum provisions
n provkiom permit
s Labor TOTAL:
CodN deemed
revoked. BUILDING
comply with such provlalone oriole pertmt Chale be BU N l
� j dremed revoked.
3 CONSTRUCTION LENDING AGENCY SEISMIC FEE D
I hereby atflrmthat them k a construction lending agency for the perform ELECTRIC FEE
Z ance ofthe work for which this permit k issued(Sm3D97,Civ.C.) TOTAL:
) O Landers Name PLUMBING FEE
H Lender's Address Qlir. ?: MECHANICAL'.FERlvIIT,' - `•"FEE"<' MECHANICAL FEE
W1mdifylhatl have read this epplationand state thatlhe above information
C fs correct.I:gree to comply with al cityand countyordinanms and state laws PERMIT ISSUANCE FEES PAID:
N relating to building convection,and hereby authorize representative ofthu
Z my to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Dale Recei t#
— (We7 agree to rave,indemmfy an d keep harmless the City of Cupertino P
agabat la les ' Smarts,mrtsand ex which may in anywayaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
agai i 1 1 cons rare o(the ting thkpernit. AIR HANDLING UNIT(OVER IO,000CFo1) CONSTRUCTION TAX
Signature of Appiiant/Contractor t3/ Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oWupahtstoreor handle harardaus HEATING UNIT(TO 100,00013TU) Date Recei t#
material as defined by the Cupertino Municipal Cede,Chapter 9.11,and the
Health and Safety Code Section 25531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' E
❑Y. I MN.
-
Will the applicant or(uNre building occupant use equipment mdevim VENTILATION FAN(SINGLE RF—%D) ISSUANCEDATEwhich emit haardous air W mamlnenk as defined by the Bay Area Air —I
Quality Marugement District? BOILER-COMP(3HPOR 100,000 BTU) YY
SYn ❑❑No IU Q
have read the hwMous materiak requirements under Chap er8.95 of BO LER-ODMP(OVER 100,000 BTID JUN 2 ` 1991
the Calfornk Health&Safety Code,Sections 75505,75533 and 25531.1
understand that lithe building does not currently hive a tenant that it is my - NEW RESIDENTIAL MECH. SQFr. -.
responsibility to notify the occupant of the requirements which=at be met
priurtobsuanceofa CertifiatecdOaupanry.
Owner or authmiaed agent Date ISSUED Bri \�
. TOTAL:
OFFICE COPY