22333 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification 7 PERMIT NO.
Building Address: 5:p, 9�/ ( under 22333
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�ner05 Cho icf 6 Sb5 1 31 CITY OF CUPERTIN66UILDINGDIVISION �`���
C..o.tor.Name: J Lie.No: APPLICATION / PERMIT
Se inn PLUlxlol 1 95� BUILDING-ELDCTRICALPLUMBINGMECHAMCAL CATEGORY OL0
Archimet/Engincer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LIC ENSEDCONTR under rDECLARATION
Ther by Scottoaffirm that lamgoa3 licensed oftheBrprovlalonsofCha essionr9de,and c- AI'PLIANCFSAEEDEMIAL JOB DESCRIPTION
Ingwlth Sect1on7000)of Division 3 ofthc Bmineasand ProfesslonsCode,and my
license le In fuB(o and effect a�'1 qG PANELS
License �Llc.p
Date, . Contractor�a's�(L4A--=_--� UP TO 2DDAMPS
ARCHITECT 5 DE LARATION Int-1003AMI'S
re !understand my plare.hall be used u public records. OVER1000AMPS SQ.FT.FLOOR AREA f/tQ.Fi.
00CC
x d U Licensed Professional SIGNS ELECTRICAL LED<< OWNER-BUILDER DECLARATION SPFOLILCRRCUIT/MIST
t, owing1hemreason.
IS,Fri Business
roessa Contractor's License law fort he P� TER
ZOO"+. following reason.ices a p 7m1$ unstrues and Profession.prove, Code: h o city or `p!/a
Z nywhlch mqulreaa permit tomrotrun,alter,improve,demollahorrepalr TEMP.METER OR POLE INST. �1
q� anystructum prlorto its Issuance,also requlresthe applicant forsuch permit to /�/
6 POWER DEVICES
V file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)ofDtvl- SWIMMING POOL ELECTRIC VALUA ON
O alon3 ofthe Business and Professloru Code)orthat he tat exem Ihercfromand
O 5 the basis for the alleged exemption. Any violation of Section 7MLS by any OUTLETSSWITCHES-FIXTURES
666 Q applicant fora permit subjectsthe applicant to a civil penalty a not morethan
eg ru five hundred dollars 015M. NEW RLSIDFNf1AL ELECTA SQ.I-T.
..�n
F-1 1,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not Intended or offered for
F O sale(See 7074,Business and Pmfasiora Code:The Contractors License law
�g does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RES.UNITS
e- who doessuch work himselforthmugh his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the W Ilding or TOTAL:
Impmverr&t issold within one yearofcompletiun,the owner-W Bderwlll have
t `den of proving that he did ewt Wild or improve fee pu rpose of sal..). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to co Its truct the project(Sec.7014,Business and Profesumes Code:
The Contractor's License Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improvas thereon,and who contracts far such pxojects with a FEE SUMMARY
c actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B h P C for this mason
OUTSIDE FLES
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N
. Owner Date re
RECEIVE N
M
WORK AN COMPEND
SATION ECLARATION FDCTURFS PER TRAP SCI IDOL TAX V_ N
I hereby affirm That I have a certifWte of consent to self-Ina w a RECEBxT N
cvmflcam.fWorkers'Compernatlon Insurance ora certified copy lhereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) —
PofIcyN WC'I-IO07iZ�� GAS FA.SYSTO.1-0VER 4(EA) RECELPTN
Com ny erICA- TPc BUILDING DI VISION FEES
Certified copy Is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
notified copy is,filed with the city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Reccipt#
(rhis section need net be completed Uthe permit Is for one hundred dollars
($100)or leas.) /ELECTR ,
I mrifythat in the performance of the work forwhlch this permit is Issued, WATER HEATER W/VENT ENERGY FEE Y— N_
1 shall not employ any person In any runner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Law.of California.Date PAID
O Applieanl Date Recei t#
Z NEW RESIDENTIAL PIMB. SQ.FT.
ZO NOIICETOAPPLICAM:IL after making pro of
should you
mus subject it the Workers'such provisions
n provision of the Labor TOTAL:
N Coda you rtwst forthwith comply with such provisions mthb permit shall be
2 j deemed revoked.
BUILDING FEE
W — CONSTRUCTION LENDING nccY SEISMIC FEL
d G Iherebyaflthat there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
= Z anteofthe workfor which this permit b ee Issred(S3097,Civ.C.) '
U O I<ncier.Name - r PLUMBING FEE
LL r Lenderapddre� QTY. MECHANICAL PERMIT FEE MECHANICALFEE
U I cartly that l have readthuappliationand slatethattheabove Nformation
O W is,correct.I agree to compiywith all cityand county ordinances and state lawn PERMIT ISSUANCE FEES PAID:
} d relating to building construction,and hereby amhorlae representatives ofthis
F N city to enter upon the abovnmentio d property for inspection purposes. ALTERORADDTOMECH.*
Z
_ Date Receipt#
(We)agree to save,indemnify an d keep harmless the City o(Cupertino
accrue AIR HANDLING UNIT CFO 10,003 CFM)
V against liabilities,,jsdgments,cansand expenses which my In anyway accrue SUBTOTAL:
ag et Bald Gty Iu co s the granting of this permit.
�^^ AI
� / R HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
,aas CONSTRUCTION TAX PAID:
B afore of Appliesnt/Cratlor D e � EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applies nt or future building occupant store or ha nd le hazardous HEATING UNIT(ED 100,000 BTU) Date Recei t#
material as defined by the Cu 8,efino Municipal Code,Chapter 9.12,and the
I lcallh a ad Safety Cadr o on 25532(a)7 HEATING UNIT(OVER 103,000 BTU) TOTAL:
Yrs
Willtheolt applicantor fumrebuilding ompantuse theequipmentAre.
VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which eMlhazardoua air inn mntsa defined by the Bay Arca Air "pur�ffl•,��
QualityManugcrrcnt Dlstri BOILER-COMP DEEP OR 103,IX108'M
4Yrs o
havernia laahaza ou'y7ode,Sections
255nb5S33 and 2M34.
of BOILER-CONP(OVE2100,000BM !EP 7 T
the
erstadtat Ifth& ildin Code, otcurnntly hvea tenant,that
C R4
understand If building c oc,g doe I not currently requir m nts which
that It busy NEW RESIDENTIAL METH. SQ.Pf. I
raporelblllty to notly the oc tof the requirements which must be urct ry
prio nccofa I' o arty.' Vf�;Qf_EaWtpN{:
croraulhrd agcmt Date TOTAL: ISSUEDBY�
OFFICE COPY