22135 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect identification - PEJUA TNO.
Building Address: - 22135
D
wrier. _:I
ane:
Q CITY OF CUPERTINO-BUILDING DIVISION
Conhactor'p Name; r ... LIQ. o: APPLICATION I PERMIT f
B=DlNGELFJCMCAL-I'LUMBINC-MECHAMCAL CATEGORY CONTROL N
Architect/Englr,eer. Lk Nm -
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE 1�-7�� I�il ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Lcensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL
JOB DESCRIPTIONIngwith Sealon7000)of Dlvidon3ofthe Buslnnsand rofesponsCode,and my - �^
limnse Is In III=dfM. i t PANELS ITl
License Clam k/ I
Date l_Z_A 7 .Contrictor
� r—r A C mmucto'S C ATO 201-IODOAMPS
as zC I understand my plana shag co
be used As public records. PS I ODO AMI9 5Q.FT.FLOOR AREA 5/SQ.FT.
Fi 0 U Licensed Pro(esslo al SIGNS ELECTRICAL
<<� OWNER-BUILDER DECLARATION Zfollowing 5PECNL CEICUIT/MISC� IherefB
byarentleat I am exempt fromthe Contractor'sLlcerue Lawfmthe
owing reason.(Section 70315,B..inem and Professions Code:Any city.,
T74dP.MECFR ORIOLE INST.
rauntywhich requires s Lssu dtloconstruci,ilsthea prove t fors tsh,orrepalr
any.tructure prbrto its leeuance,elso requlrestheappllant forauch permit la POWER DEVICES
file a signed statement that he Is licenced pursuant to the provisions of the
iOµ Contractor's License law(Chapter 9(commencing with Section 7000)of Dial. SWIMMING POOL ELECTRICELECTRICVALUATIO,N.,`
i. Ston 3 ofthe Sunman and Profenlns oCob de)orthat he emmpttbemlmmand
O the basis for the alleged exemption. Any violation of Section 70315 by any 1 OUTLETSSWII'CHFSHXNRES L �3 Q Q, V
applicant for a permit subjects the applicant to a civil penalty of not morethan
five hundred dollars($S00).
l,as owner of the roe NEW RESIDENDAL ELECTR SQ.FC. STORIES TYPECONSIRUCTION
compenp p rty,car my employees with wages r their sok
7` Ask(Seeatlon,wuldothe r.and kandthes ractuare is Code:The
Contractor.WelledLaff Law
O
Ask(Sec.apply
to show and Prooperty hob:The orimprthemeLaw
;$ don nonsuch torn ownero/prosighison emoymprovnthereoryand
ch OCC.GROUP RES.UNITS
ahaovements are nor rose dedorwghhlsowne.If,ho however,
that
Improvementsarenotintended earafredfor pictio,If,however, ilder illhading car TOTAL: 1
improvement lswld within one yearafcmnplelbn,the owner-bullderwlllhave
the burdan of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLCODZONE APN.
E]I,rue owner of the property,Am exclusively contacting with licensed
contractors m construct the prefect(See.7044,Busmen and P f.lon Code: PERMIT ISSUANCE C�
The Co radar's License Law don nor apply to An owner of property who
Wilds or Improves thereon, and who contracts for such plojeoA with a ALTER-DRAIN&VENT-WATER MA) FEE SUMMARY
egBjTadon(A)Ilcenxd ponosnttothe Cont.cme.License Law. BACK FLOW PROTECT.DEVICE
[_J I am exempt under Sec 0 k P C for this reason
OUTSIDE FEES
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y N
Owner Date RFCE1PT 0
WORKMANCOMPENSATIONDECLARATIONFIXTURE2 S�TRr SCHOOL TAX Y N
�I hereby affirm that 1 have a certificate of consent to eel(-Insure,car A 7 RECEIPT a
certlfiateofWmkere Compa..it..Insurance nacertifled mpythere,felee. GAS EA.SYSTEM-1 INC40UTI.E15 PARK FEE Y N
Policy
Lab CJ RECENT M
Polity n - GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Com any -
�CertlMdropylaherebyfumiahed. CREASE/INDUSIAL WASTE INTERCEPTOR PLANCHECKFEE
ertifed copy is Ned with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.200PI: Date RCCeI t#
IThissection need not he completed lithe pemdt b foronshundred dollars
($100).,tem.) WATER HEATER W/VENT/¢FCTR' ENERGY FEE Y_ N_
I certify that In the perfomrunceof the work forwhich this permit Is Issued,
I shall not employ an/person In any manner,so n to become sub)ect to the WAY1R SYSTEM/TREATING
Workere'Corepensation Laws 6TINIfomh.Date PAID
• Z Applicant NEWRERDPIMALPLMB. SOkf. r Date Recei t#
Z O NOTICETO APPLICANT.
If
after making this CertBlcale of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
V) Code,you mu at forthwith comply with such provision rthis pemdt shall be U N
G FEE
W j deemed revoked.
G CONSTRUCTION LENDING AGENCY - SEISMIC FEE ^l
Ihereleyaffiren thattherebaconstructlon lending agency forthe perform- TOTAL: ELECTRIC FEE 4
Z Anne of the work forwhich this permit is heued(See,3097,Civ.CJ
00 Lender.Name PLUMBING FEE O
LL I— Lander.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedifythatl have read this appliationand statethat theabove information
4 Iscorrect.I agree to comply with all cityand county ordinances and state laws PERMITISSUANCE FEES PAID:
>. N relating tobullding construction,and hereby auth represenhhvesafthis
city to enter upon the above-mentioned property rinspectionpurposes, ALTERORADDTOMECH.
? (We)agree to ave,Indemnify an d keep h en the sty of Cupertino Date Recei t#
U against Rabllltka,tadgmenb,". adexpen whtcheraylnanywayaccrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against said City In consequ f the gra g f tins permit.
p i AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Appltaht/Contractor Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or future building occupant store or handle hazardous HEATINGUMTCM100,000STID Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Codlk3xHon 75532(a)t HEATING UNIT(OVER 151,000 BTU) TOTAL: XF
Yes 20 No
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
w mi
which et hazardous air contaminants as defired by the Bay Area Air
ality Management 'trtct2 BOILER-COMP OHPOR 100,000 BTU) PA
�1y.
Yes No aP`�/'jid
have read the h mus materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the GlBanta Health&Safety Code,Sections 25505,25533 and 25534.1 ' ^v
understand that if the building don ect currently have A tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT kll ��ryry,�
reaposuibility,to a By accupan of the requtrements which moat be met
prioriolesuxnce tOcateo Edney. r�
Owner or/authorlaud agent Date to
ISSUED BY:
TOTAL:
OFFICE COPY