22570 (2) APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES — USE BALL POINT PEN ONLY
' Buildingoti
Project Identiflon - PERMITNO. 'aaa���a r
BuOd o Address: '/'/2255 O
�' C
sine: ane:
/v CITY OF CUPERTINO-BUILDING DIVISION', f�l�_ /D C11
c Name:'i 55 ua.No APPLICATION'/PERMIT LJ zY 1I
G BU[LDING-ELECTRICALPLUMBINGMECFIANICAL CATEGORY CONTROL X
Archlteci/Engineer. - Lt.Nce '
QTY ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
Address:. `' POWTISSUANCE ❑ I�
LICENSED CONTRACTOR'S DECLARATION IfC�
I hereby affirm that l an,licensed under provisions of Chapter 9(commeno APPLIANCES-RESIDENTIAL " JOB DESCRIPTION
Ingwith Se on7000)of Divisim3afthe Busimmand PmfesslonsCode,and my - -
lknow is in full farce and effect. PANELS
License Class 'LICX
Dale Contractor
ARCHITECT'S DECLARATION 201-10DOAMPS
qZ I understand my plans hall be used as public records. OVER I(DO AM79 SQ.FI.FLOOR AREA S/SQ.FT. .
q��++ °C �.L E D .I N`.
6i 0 is Licensed Professional SIGNS ELECTRICAL - -
tt'�-tL0'1 OWNER-BUILDER DECLARATION SPECiALCIRCUIT/MLSC ' '^
�.., I herebyaffirn that l am exempt fremthe Contraeorb License Law for the C6•/ TER,
fallowing reason.(Section 7031.5,Business and Professions Code:Any city or TEy,P,METERORPOLE INST. '
DAM xaaassaaaasaaass�ssa
�, countywhich requirma perndttemnstrur,alter,improve,demolbh,orrepalr �� W 6/ -
a anystmu mprior Wiblmame,alwrequirestheapplcantfoi'euchpermitto POWER DEVICES 'c�1JJ
f C T V file a signed statement that he b licensed pursuant to the provisions of the
3:8 CoMram.en License Low(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC . VALUATION
{.. O si6n3ofthe Businnsand Profemiom Code)orthathebexempttherefromand -
�y�0 Y13 the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETS-SWITCHESFIXTURES
applicant fora permit subjects the applicant to a civil penny ed not nnrethan
five dreddollam($500). NEW RESIDENTIAL ELECTR - SQFT. STORIES TYPE CONSTRUCTION
7 e owner of the property,or my employees with wag"as their sole
c pensation,willdothework andthestrir misnotinlendedoroffered(or
Ole(Sec.7094 Business and Professbm Code:The Contractors License Law
r�$ durance applytoan owmro(propertywho bulldsor Improvestherem,and
who doessuchwork him "
selforthrough hisownemploye ,provided thatsuch ' OCC.GROUP RES,UNITS
q Improvements are not Intended aroffered forsale.If,however,thebulldinger TOTAL: -
n/�/ Improvementbsoldwlthln omyearofcompletion,theowner-bulderwBlhave
tbg burden of proving that he did not bund or improve for purpose ofsals.). QTY. PLUMBING PERMIT FEE FLOODTDNE APN
M I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE - }
contractors to contmet the project(Seo 7046 Business and Profession Cade: ,
�J The Contrador.License Law does not apply to an owner of property who
{ Wilds or improves thereon,and who contracts for such p(ojects with a ALTER-DRAIN&VENT WATER(EA)
I ctor(s)Bernard pursuant tothe Contraor's License Law. FEE SUMMARY
ctam exempt under,Sec B&P C for this reason �c�FLOW PROTECT.DEVICE
151 -
OUTSIDE FEES
DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N
Omer Date RECEI'T X
'f WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP, SCHOOL TAX Y_ N
❑I hereby affirm that I have a certificate of mnent to self-ineurs.ora J EpT N
mAifimteofWorkera•Compenali=Insuranmara"etifledmpythereof(Bec. GAS EA.SYSTEM-IINCAOUTLETS PARK FEE Y N_ I.
3800,Lab C.) -
Policy X - RECEIPT X
Cum any - - GAS FA.SYST M-OVER4(EA) .BUILDING DIVISION FEES
Certified copy is hereby fuMshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE' -
' FICertiffed copy is filed with the city Inspection division. ` _ 1 .
CERTIFICATEOFFXEMPTION FROM WORKERS' . GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20081• Date Recei&
(Thio se[Ien need not be completed if the permit boron hundred dollars
(Sl D3)mfWATER HEATER W/VENT/E.ECTR ENERGY FEE �Y_ N_
' Icertifyththat Mthe per(amance a(thewmkforwhich this permit Is blued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers,Compensation Laws of California. Date PAID
O Applicant Date Rch ei tN
Z Z NOTICE TO APPLICANT;If,after making this Certificate.f Exemption,you NEWRFSIDEMHALPIMB. SQFI.
Qshould become subject to the Workers'Compensation provision ofthe Labor TOTAL:
N'
Code,you=at forthwith comply with such provlslons orthiI permit shall be B G •E s
jdeemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE '
CL Iherebya(firm that there Is comminution lending agency for the perform TOTAL: ELECTRIC FEE
M Z ance of the work for which this permit b Issued(See.3097,Civ.C.) -
(.) 2 ]enders Name 'PLUMBING FEE
LL !- U.der.Addresa - - QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythat I have readthb eppllmtionand rtatethatthe above information -
C Iscorrect.I agree tocomply with all city and munly ordinances and stare laws PERMIT ISSUANCE '-CD FEES PAID: '
N relating to building contraction,and hereby authorize representatives of this
.(_ Z city to enter upon the above-mentlomd property for inspection purposes.. ALTER ORADDTO MECH. ,
(We)agree to save,indemnify an d keep harrniew the City of Cupertlm - DRte Receipt#
V against lbblll les,jud menta, d expeasea which may In any way accrue AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:-
agalra Id in n the grastlogoithl permit.
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
re o(AppBran[/ . ra r Date EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA OU MATE LSDI LOSURE
1l the applicant or future building ocev ore or handle hazardous• IIFATINC UNIT(TO BTU) �Cb Date Recei tri
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
limltharxl Safety Code Smile.25532(.)7, HEATING UNIT(OVER 100,D00 BTUI - ",TOTAL:
Yee - I]No VEN'fIIATION FAN RESID)
TVIV the applicant or future bcllding rampant use equipment or devices -ISSUANCE DATE
which Pict hazardous air contaminants as defired by the Bay Area Air -- ggiYpp ppppaa��
1; Ilty Management Dls N. - BOILER-COMP(3FQPOR 100,000 BTU) a P'4'ilTl`,s11
Yes LIr'U7 No
have read lM1ehazar�ous materia.requlrementsunderChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) . -
theCalifornbHealth&Safety Code,Sections 25505,25533 and25534.11111(
understand that ifthe building-do"not currently have atenant,that ltismy NEW RESIDENTIAL MECHAUG
. SQ.FI
responsibility to notify the occupant of the requirements which moat be met ' -
priortoissuance of a Certificate of Occupancy. _ /y/aa
per , -
' Owner or authorized agent Data,
te. � - ISSUED BY;
-
OFFICE COPY v