22928 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO22928
. ^ /''�
Building ddress: S
ZDV� ^ W / /Q /�e CITY OF CUPERTINO-BUILDING DIVISION
come ^, y-pc.No: APPLICATION /PERMIT l Z
• Aahltect/EAlnmr. LIe No: BU[LDING-FbECTRICALPLUMBING-MECHpMCAL CA RY CONTROLX.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISUANCE -V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
bmthat lamlkmeedubeerprovisions of Chapler9(mm
men AI'PLIANCESRESR)ENML JOB DESCRBI'ION
ingwlth SccAoSecHon7000)af DlWsion39fthe Businenand Pro(euton,Cyde,and my ,
license le In full(prce and effect. / PANELS p/ f'
Lloen,eC L Lk.X S 7 _/ /1 O- X�'_ �[i�/ C--`
Date Cmdras r G Slat.
ARCHITECTS DECLARATION 201-IOUOAMPS
q�++0 ZO Iundentandmy,Plans shall be used as publicreo its. OVER I ODO AMPS SQ.FE.FLOOR AREA S/SQ.F7.
Fi Licensed Professional SIGNS ELECTRICAL
< OWNERSPECIAL
BUILDER DECLARATION :MWM�®
{ten a CIRCUIT/MISC
LQ, Thereby affirm that exempt Contractor's License law for thest
O 2 ti following reason.(Section 70315,Business and Professions Code:My city or TEMP METER OR POLE INST.
muntywhlchmryinnaper ttommt d,alMr,lmpmve,demollsh,ormpalr
anystmct mpdortolbiawance,alsomquimstheappllantforsuchperMtto LOWER DEVICES
O file a signed statement that he is Ocensed pursuant to the provision,of the
I 31„y Contractors Licen,e Law(Chapter9(commencing with Section 7DOO)of Divi- SWIMMING POOL ELECTRIC VALUATION
F Oa sion 3 oflhe Business and Pmfeaslon,Code)orthat he is exempttherefromand
�'•.1 the last for the allegedexemption. Any violation of Section 70715 by any OUTLETSSWITCIffBHX.TURFS
< appBantfora permit subjects the applicant to a civil penalty of not rrore than
fivehundredd.1husaf500). NEWRESIDENTIALELECTR SQ.FF. STORIES TYPE CONSTRUCTION
nL as owner of the property,or my employees with wages as their sole
compen,ation,Mli dothe work,andthe structure Lance Intended or offered for
Osale(Sec.7004,Business and Professions Code:The Contractors License law
R does nm apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS UNITS
EEw whodocasuchwmkMmrelfarthmugh Msownemplayees,providecithat such KrE
Improvamontsarenon intended orofferedforsale.IThowevegthebuildingor TOTAL:Improvement bwld withnomyearofwmpletlogtheawner-buMerwill lovetl�urden of proving that he didnmintild orteoprove fm purpose o(sale.). QTY. PLUMBING PERMIT FLOOD TONE APN
u 4 an owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7004,Business and Professions Code:
The Contractors License law don not apply to an owner of property who ALTER-DRAIN k VENT WATER(EA)
Wilds or improves therecon
on,and who tract. for such pk sects with a FEE SUMMARY
cgWp+ctor(s)Banrd pursuant to the Connector'.License Law.
U I am exempt under Sec. B As P C for this sawn BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIVER
WORKMANCOMPFNSATIONDECLARATION
i' ❑I hereby a((Irm ce (locoif
that I have a rtlte of consent to -Insure,or IrIXTDRES•PER TRAP SCHOOL TAX Y_ N_RECEVI'X
certificate of Workera'Compen,atlonleunnce or a certified copy thereof(Sec. GAS EA.SYSEFM-1 INC.4 OUTLETS PARK FEE Y N_
3800,Lab C.) RECEIPTX
On X GAS ER
EA.SYSTEM-OVER Com ray BUILDING DIVISION FEES
On
copy is hereby furnished. GREASE/INDUSIRL WASTE IN'T'ERCEPTOR - PLANCHECK FEE
[:]Ccrllflcd copy b flied with the city W pectlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDgM EA 200FT Date Repel ted
M
(Thlsslon need na becompleted if tho perre t b for one hundred dollars
(SI00)orlesa.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work for which this permit is issued,
I sha0 nm empty any person in any manner w as to me pct ted WATER SYSTEM/TREATING
Work eraC Ion Lws orBfcc..11(ornla.Da / PAID
O A Meant I�TLS4 Y1 l-s2 Y�v Date Recei tit
2 PP NEW RESID=- AL PLMB. SOFT.
Z O NOTICE TOAPPLICAM:H,after Workers'Compensation
pe CertnlaovidenExemption,the
aM1wld bemire subject to the Warkers'Compen,atbn provision,o(the Labor TOTAL:
(/) Cad,you most forthwith comply with such provisions mthb permit shallbe BUILDING
� > dmro
eeed oked.
tJJ aCONSTRUCTION LENDING AGENCY SEISMIC FEE
d [hereby affirm that there is a mn,trurtlon lendingagenry for the perform, TOTAL: ELECTRICFEE
D Z an oftheworkforwhichthbper bLa (Sec.3097,CIv.C.)
O O i<nder'.Name Ty, MECHANICAL PERMIT E PLUMBING FEE
LL F Lender's Address Q MECHANICAL FEE
O W ce
Irtlfythatl have readthb application and statethdtheabovei immosttan
IL Is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby,authorize reprexntatives of this
F Z city to enter upon the abovo-mentlonel property for inspection purposes. ALTERORADDTOMFGH. Dale Reeeiptlt
(We)agree to save,Indemnify a keep harm1csa the City of Cupertino
V agaln,thablRtb,jad ments,custsxpenses hichmaymanywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
kr"MrMyci con can hegrant this permit.
AIR HANDLING[INTI(OVER 10,000 CFM[ CONSTRUCTION TAX
gnature o(Appant/Contractor Data EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATINGUMT(TDIM,(s)( OTT, Date Recei Hf
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)? HEATING UNIT(OVER IWW BTU) TOTAL:
p-
RYea M No
III the a ppllant orfuture building occupant use equiprrent or d colors VENTILATION FAN(SINGLE RESID) ISSUANC}a�TE
which emit harardous air contaminants as defined by the Bay Area Air Y Ma �1
Quality Management Dsn�''trIict? BOILER-COMP OHP OR 100,000 BTU) 1
[?have read the hazar`Irousamaterials requiremcnb under Chapter 6.95 of BOILFR-COMP(OVER 100.000 BTU) OCT 31 1991
the Calf(omla Health 4 Safety Code,Sect lore 25505,25533 and 25534.1
and cntand that if the building does nor currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr Ilry/`V
responsibility to notify the ocupant of the requirements which must be met ^IIY Ur �VI7tH
prior to Lauanm of a Certificate of Oaupa ory. V
/t` /Ux
Owner or authorized agent Data TOTAL: 1ISSUED BY: AU -
OFFICE COPY