22400 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PDMITNO.
BalldinB3d7>
was 22400
mer a-3eante7 i-rone; A
/ •ell Z C25rk CITY OF CUPERTINO-BUILDING DIVISION
ca^l.,•tar•N•^�e: / '7�' Le.No: APPLICATION I PERMIT -7 —g
• ^�
.eae� S'C.d"' SI UM
BUfLDINGMEGTIUCAL-1•LBINGM
MECHACAL CATEGORY CONTROL a
Archircct/En r. L1c No: ir,f • BUILDING PERMIT INFO
'Q _' a.AAELECfRIC PERMI'fy :r^ `''FEE. `
Address: ❑ Ifs ❑
PQIITIS6UANIE JI�X-I
LICENSED CONTRACTOR'S DECLARATION
thereby
hermthat lam licensed
under rovWonao( 9(commnc APPI2ANCESRESDENf1AL ]Og pFSCRBDON
ingwthSediOn7000)ofDiWdon3o(th.B.MnsmdProfm.i..Code,andm
hoar"Is in full fo and effect. PANELS
. Li..wChn- LI.1tor53y5/6Date I acUPT02DIDAMPS
� yQ
ARCHITECTS DECLARATION 201-IOW
OZ I understand my plansshallbsusedupublicmoods OVER1Wil AMPS SQ.Fr.FLOOR AREA S/SQ.Ff.
O
�Z�j Llanted Professional SIGNS ELECTRICAL
n< OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/MISC
7o 1lumbyafimthat l amexempt from the Contractor:Lim.Law for the
Q following Mason.(Sectiw 70315,Business and Professions Code;My city or
t"'uypp .ntywhlchrequbeaapermltlowmtmat,alter,impr ,demolbh,ormpAr TFMP'METER ORPOLE RJSf.
d 7 anystmature prloto its Issuance,also mqubntheappBont forsuch permato POWER DEVICES
yz
file a signed statement that he Is BansM pursuant to the provisions of the
Ors Contractor's License Lav,(Chapter 9(commencing with Stolon 7000)of Divi-
X05 ai=3o(the Sud madProfmioms Code)orthg hebesorptthemefromand SWIMMING POOL ELECTRIC VALUPON�•0asrY
S^ the basis for the alleged exemption. My violation of Section 7015 by any OVTLETSSW[TCF♦FSFTXTURES `V CDO.JL Wapplicant(ora permb subjecte the applicant to•civil penalty of net room than
? fivyejtu^dnd dollars ISM. NEW RESIDENTIAL ELECTR SOFT. STORIES TYPE CONSTRUCTION
j. L as owner of the property,or my employ.with wages as their sole
_2C compensdion,willdothe warka^d thestmchm is not lnteMed or offered for
❑ u1.(sea 7004,Bi...d Peofmions Code:The Contractors License law
y�j $ don not apply to an owner of property who builds or improves thereon and OCC.GROUP RFS.UNITS
who doessuch work himself or through his..employ.,provided that such
improvements arc not Intended oroffered for sale.If,however,thebullding or TOTAL:
improve.aiswldwithinoneyearo(completion.lheowner-bullderwBlhaw
tlp, urde^of proving that he did not build or improve for purpose ofale.). qN. '-" ..,PLUMBING PERM17-',"Y f� ,, FED^� FIADD7ANE APN
u L as owner of the property,am exclusively m^traciing with IimaM PERMIT ISSUANCE ��
mntraclon to mwwo the proea ject(S7004,Business s and ProfeuimCode:
11e.Contractor's Llmnee law don not apply to an owner of property who
Wild*or Improve therton,and who contracts for such ptojem with• ALTER-DRAIN kVENT-WATER(EA)
ot�dm(s)lce
insed p...ttotheCwtmdon.Limree Law. %`FEE,SUMMARYe-,^ '
LJ I am exemp under Sm B k P C for this reason BACKFLOW PROTECT.DEVICE
!!??pp Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIef
WORIO.tAN COMPENSATION DECWRATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
bl nemby aHUm that I have a nrHflute of consent to sell-Insure,ora RECEU78
certifioteofWmkerC Compensation lru ..ore nmtiied copy thereof(BeaGAS EA.SYSTEM-1 INC4OITD.ETS �C70 PARKFM Y_ N_
3800,Lab G
Policy• RFY_EB' a
Com anv A GAS EA.SYSTEM-OVER } n T ^ 6DILDING DI VISION FEES
Certified ropy le hereby furrdhed. i... PLANCF3ECK FEE
Certified copy h filed with the city inspection division. GREASE/INDUSIRL W Q'Lit
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP J 'PA
COMPENSATION INSURANCE SEIA'FR-SANITARY-STORM EA.200FT Datef Re i t#
CIMS Notion need not be completed If the permit Is for one hundred dollars
(910(tm 1m.) it Y FEE, Y N
IcadHythat In the pedomsnca of the weak for which this permit is issued, WATER HFATMW VENT/ _ —
I shall not employ any person In any manner an at to become subject to the WATER SYSTEM/TREAnNG PAID
Workers CompensationlAwsof CaBfomh.Date
Is Z Applicant NEWRESIDENTIAL PLMB._SQ.FT. Date Recet t#
O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Wod ori Compematlon provisions of the Labor TOTAL:
N
Code,you=9 forthwith comply with such provisions or this permits hall be BUILDING FEE
LI > deemed revoked CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
1 Ihereby a(firmthat there L aconsmudlon lendingagencyfarthe perform- TOTAL ELECTRIC FEE
1 Z ancrofthe workforwhichthb permit is issued bee 3097,CW.G
) O lander:Namn - -PEL PLUMBING FEE t
L 1- Lender's Address ori'. `";�'Iv1ECHANICAL: RMIT:+' FEE1-t, MECHANICALFEE
3 W Imnifylhatl havereadthisapplioti^nand tlalethattheaboveln(omutiw FEES PAID:
Q. isconeo.Imli etommplywlthaticltyand muntymelinanmand statelaws PERMIT ISSUANCE
W relatingtobullding constrooio4and herebysuthorize reprametativesofthb
Z cityto enter upon the above-mentioned property for inspection purposes. ALIERORADDTOMMH.
Date Re[ei t#
(We)agree to save,Indemnify an d keep hamnim the City of Cupertino
againstllabWthap' cig b,coksand"Per
which may in anywaywaue AIR HANDLING UMI CFO 10,000 CFM) SUBTOTAL:
against aid i le en oIt' tingofthispemnit.
my n AIR HANDLING UNIT(OVER 1o,OWCFM) CONSTRUCIIONTAX
Ig A can
ontrad r Date D 0 RUST HOOD Iv/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Itheapplicant ofuture building onvpant store or handle hazardous ITFA7IM1G UMT(TO 100,000 BTU) Date ROCeI t#
s m,crislasdefineel by the Cupertino Municipal Code,Chapter 93 Z and the
Health and Safety Cade Section 25532(x)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: t
❑Yes MN.
Will the applicant orfuture building occupant use equipment ordevi. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamlrunth a defined by the Bay Arca Air
Quality Management D'str447 BDILER{OMP OHPOR 100,000 BTU
.y
No
4Yes
h .e.dmehau�wamale ab equlrcmenbunderChaper6.95ef BOEER•COMP(OVER 10,000BTU)
the CalHomUHulth&SafetyCode,Sediow255O5,25533a^d7553M.1 JU�
. a1s,OQ�
understand that if the building dnot currently have a tenant,that B 6 my NEW RESIDENTIAL MECH. SQFr. /:IyJ
responsibility to notify the occupant of the requirements which most be mel
Prior to issuance of a Certifiate o(O.P racy. •las w[
Owner or authorised agent Date TOTAL: ISSUED BY: Y W
OFFICE COPY