22009 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
Building Projerudentifiation PMWT NO.
BuildingAQ Ori 22009.
iers ams: one: APFUCATION SUBMI I I AL DAI�
P"Aj —Sj CITY OF CUPERTINO-BUILDING DIVISION
Comer sN.me: Lk.No: APPLICATION / PERMIT C
L J BU(LDINGELECTR)CAL-PLUMBING-MECFUMCAL CATFIARY CONTROL/
Anhltect/Engineer. Lk.Na N T•1
0 Y! 1V- LECTR
_1EIC PERMITt FEE. 'r BUILDINGPERMIT INFO r
Addrou: PERMITISSUANCE I�
LICENSED CONTRACTOR'S DECLARATION �C11
I hereby affirm that l am Uxpund under provide..of Chapter 9(mmmn APPLIANCES-RESIDENTIAL JOB DFSCRIIefION
Ing with Section 7000)of Divt.san 3 ofthe Bus ne sand PmfeWonaCede,and my T
license is in full d d(ect. PANELS / f
Llanm(�Lk.s / N(j/ (L
' Dae /E Contnctor
ARCHITECTS DECLARATION IDI-1000 PS
O I Z I understand my plant.hall be used u public rtmNa OVER I O00 AMPS SO.FT.FLOOR AREA S/`.Q.FT.
EL0 Ltconsed Professional SIGNSELECTRICAL
C OWNER-BUILDER DECLARATION SI'FLUL CIRCUIT/MiSC
p„ 7� 1herebyaf0rmthat lameaempt frotnthe CoNnreor'a License Lawfathe
op ppp following reason.6ection 70315,Business and Professions Code:Any city or TEMP MLTHt OR POLE INST.
county which requires a permit to commuct,alter,Improve,demolish,or repair
anyse mpKamlb Iswana,ahonqubestheappumtfasochpermltm ppWpR DEVICES
foe a signed statement that he Is Bansed pursuant to the provisions of the
_3�t`n Csntnctori Lkenu Lw(Chapter9(mmnencing with genion 7000)of Divi- SWIMMING POOL ELECTRIC VALUATIOy
C aloe3oHheBusinmandProlmb,c,a)orUat hetsexempttherefmmand O ✓a
y the W W(or the alleged eaemplfor. Any violation of Section 70315 by any OIJTLEISSN7.[C}ffSpD('f VRFS !)
a applicant for a pem it sub*utheapplicant to a civil penalty of nut more than
:n• � frv,£h,undred dollars(55000. NEW RESIDENTIAL ELECIR SQXT. STORIES TYPE CONSTRICTION
... u1,u owner of the property,or my employees with wage as their sole
CZE mmpensufon,will do the worl:and the structure Is not Intended or offered for
O
Is 5es.7016,Business and Prufmions Cade:The CmdrectoY.Liame law
' $ don mol apply to an owner at property who build+or Improves thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhlmselforthrwgh Nsownemployen,provided that such
improvemerpsare not intended oroffered forsale.If,however,thebullding or TOTAL:
improvement Issokl within owyearofecmpldbn.thewvner-buuderwW have
tlP,kuNenofpmvingthrt he did wtbuud orlmprove forpurposeof..k.). QI'y,�`. PLUMBING PERMIT,: FEE'- FLOOD ZONE APN
U L as at of the property,am exclusively omtnnlng with Ilansed pt7(MD.LSUANCE
mmm�mto mnswcttla project(See 70G,Bwlnmand Profmians Code:
The Codranot•Liam Law don not apply to an owner of property who
builds or irove mpthcontracts ereon,and who contfs,such m ptojewith a ALTER-DRAM k VFM•WATER(EA) ;t_i -,
onadorWuauMpunuanttothe Cmn does Llarue Law. B CI:�TAWMOTECT.DEVICE \�l i - '•':FEE.SUMMARY m,',. her.,
LJ OUTSID
I am exempt under See B k P C for this reason ^ SANITSANT A
Owner Date NS FLD6X ROOF,AREA,COND. 1 ARY RECEIrI'If
WORKMANCAMPFNSATIONDECLARATIONFIX7l1RFS PFR.DUP SCHOOLTAX Y_ N—
�� ❑I hereby aHlm that I have a certificateof consent m aeu•Inwrt,a• RECEPT a
certificate of WorkeriCompemation lnsuana or a certified copy thereof Ike. PARKFEE Y N
Policy
0 C.) ` —
Po11ryF O RECEITN
Company L ` eta GAS EA.SYSTFAf-0VER4(EA) BUILDING DIVISION FEES
� copy la hedwith the
city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertNedcopybfiledwith i&city Inspection division. /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP $TOTAL: ELEWIC
D , t
COMPENSATION INSURANCE SEWFR-SAMTARY-STORM EA 7e e 1 t#
(Thin section need not be completed lithe permit Is for one hundred dollars
O1D0)alm.) WATER HEATER W/VENT/ELEY —
I artifythat in the performance of the work forwhich this permit Is Issued.
I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TREATING
Waken Compewlion Lws of Ciufama.Date
0 Z Appllant NEW RESIDENTIAL PLMB. l Recel 1N
Z O NOTICE TO APPLICANT:B,aher making this Certificate of Exemption,you
should become subject to the Wmiums''Cempemation pcovitions of the Labor TOTAL: Y
CC N Code,you at forthwith comply with such provision or this permit shall be S 17
deemed revoked.
LU � CONSTRUCTION LFIJDING AGENCY
CL G 1herebyalfrm that there Is a construction lending agency for the perform- E IC FEE
M Z ante olthe work for which this permit Is Issued(Sm 3097,Civ.C.)O Lender'.Name UMBING FEELLH lender.Address QY. ' MECHANICAL-PECHANICAL PEEOW IaKlfyth.tl have read thIsappuationand sumthatlheaboveinformitlotS PAID:d Iscomen.l agree to comply with all cityand county onuranmand state laws PERMIT ISSUANCErelating to building corestruction,and heabyauthar@e representtive,of thiscity to enter upon the aboverrentimed property fa Wpection purposes. ALTERORADDTIOMECH. Date ReCe' tN
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V
against Wb ,jadgmenb,cott's d penseawhichmayluanywayacwe AIR HANDLING UNIT(TO 10,000 CFM) SUBTO AL:
.int o gamin 1.
AIR HANDLING UN7T(OVER I0,ODO CFM) CONSTRUCTION TAX
Signature of Appllant/ nor Dab EXHAUST HOOD IW/DUM CONSTRUCTION TA PAID:
HA OUS MATERIALS DISCLOSURE
Will the.ppuant ftu
ure building occupant store or handle hazardous HEATING UNIT CID I 00,01f)BTI7) Dale R t IN
material as defined by the Cupertino Municipal Cade,Chapter 9.12 and the
Healthand Sifety Cade Section25332(a)I HEATING UNIT(OVER 100,000 BTU)
❑Yes In No
Will the applicant orfulure buildingoaup.muss equipment ordevice. VENT(IATION FAN(SINGLE RESID) ISSU NCE DAtE
which emit hazardous air contaminsnb as defined by the Bay Area Nr
Quality Management Dimrlctl BOILER-COMP OHP OR 100,0()BTU)
Yes Q1�No Q
1havertadthehax. usmatcrialsrepim enbunderChapter6.93of BOILER-COMP(OVER100,000 BTU) ( R
the California Health k Safety Code,Sections 75505,25533 and 75534.1 05
u ndersta red that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECA. SQ.FT /
responsibility to notify the occupant of the requirements which must be net 4
Prior to issuance Of a Cor ifiate of occupancy. A
Owner or authariud agent Data TOTAL: ISSUED
OFFICE COPY