22937 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add : o z 22937
�r mr one
CITY OF CUPERTIN4BUILDING DIVISION
erect or'.Name: Ik.No:L) APPLICATION if PERMIT
`�" '�� •—`'b ` r Z-6o BUILDING-a ECTRICAGI'LUMBINGMECFUMCAL CATEGORY CONTROL'.
Archdect/Engineer: _LtN
33 4 L� Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. O ( oK I)C PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that T am llcenaed under p.Wonaof Chapter 9APPLIANCESRE9DEM L JOBDFSCRII N
ingwith Section 70(10)of qv W on 3 ofthe Budnev and Pmfe W¢uCode,and my
I lm. In effect. •LU � 4� PANELS
Date Clan 7Jc Y
Date GOntmCor o f(it UIJ L 4
ARCHITECTS DECLARATION -1 000 M115
MZ Iurderamrdmyplaw.haDbeuaednpubBcrecmdA OVER 1000 AMPS _ ffF(500� $/SQ.FT.
O
F LI¢nscd Prd®Wrul SIGNSELECTRICAL
UT
<� OWNER-BUILDER DECLARATION SPECIALCTRCUIT/MISC 1 Q
IhercbyaMrm that l amexempt frenthe Contractor.Lkrnse Lawforthe Y ' l
67 folbywhieason.(Senlon7mt toonainaesa alter,
Code:Mycttyor TEMP,METFRORPOLEINST. q
F�k� many which requUeaa perMttomrutruct,alter,lmprove,demolbh,ormpalr 1-116
[raj any sweturcpd«toltshan he I,abused punhattothe f¢achpermlte PCnVEA DEVICES CCC (O
file a algned rfa4ment tlut M b IYenaed pursuant b the proalbr�d the
F,Fe Contractor's Umnae Law(Chapter 9(comneenctng with Section 7ODD)of DIv4
, sbn3ofthe BuWaeasand ProfealavCod0orthat helaeumptthertfmmand SWIMMING POOL VALUATION
< the barb for the alleged exemption. Any violation of Section 7m15 b/any
appH.tforaper .b*e theapp&antt..tl 1pe.hyd.&.o thao TCF�SS]-T%i11R6
w ° five hundred dams(Isom.
..
F-1 7,as owner of the property,or my employees with wage,u their.ole NEV`R®ENnAL ELECTR SQ.FT, STORIES TYPECONSTRUCTION
cvmpelaatlon,wW do the work,and the structurcb not Intended or offered for
sale Sec.7UµBasin.,ant Profeabro Code:The Cor dol.Urease,Law
S$ don rot apply to an owner of property who Wild.or Improves thereon,and - OCC.GROUP RES.UNITS
who d«asuchworkmaeB«
hlthrough hlaownemployen,provldedthat such
imprvvenenb are not Intended oroHered!¢sale.If,however,the building on TOTAL
Improvement held nithinonsy<ardcarapletbgthsowner-bullderwlll have
th CjZurden of prwing th,t he did not build or lmpr for purpose of aa4.). QTY, PLUMBING PERMIT FEE
LI 4..owner of the property,am exclusively ng with Ifeera d FLOOD ZONE AIN
contraeton to comtruca the protect(Ser.70K Banh ea and Prdmlou Code: PERMIT ISSUANCE
The Contractor'.Lim.Law don n¢apply to u owner of Property who ALTER-DRAW A VENT WATER(E,U
Wild. or Imw
peea thereon, and who contracts for such M"s•with.
fit(+ct¢(Uu¢ued pumuantt.hm ContnGoh Uc,r.LW. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I sen e.eerpt under Sec B A P C for tMs masonOUTSIDFF
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner Dae RECFR7Y
WORKMAN COMPENSATION DECLARATION FWTURFS PER TRAP SCHOOL TAX Y N_
❑1 hereby.((Iron that I have o certificate d cmaaent to copy
thereof
• RECEIPT Y
38M,lAcerriffica4d Worken'Comp<wtlonlmunn¢ea¢Nfled copytheeeof Sacs GAS FA.SYSTEM-11NC4 OUTLETS PARK FEE Y N
38(q,IAb C.)
1 icy Y GAS EA.SYSn]d-OVER 4(EA) RECEIPT Y
Cat ray BUILDING DIVISION FEES
ETZY-L ed copy b hereby furrdehed. GREASE/W WSIRL WASTE INTERCEPTOR
FEE
❑Certified copy b fuel with the dry lmpe odivwon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE ypRS4M.1.,4gY y-TOghl�XppT Date Reeel t#
(this section need n¢be cenpleLLd Rthe permit 6(fe on<hundned dDllue
(II m)«48J WATER HEATER W/VFxT/Ef.ECTR ENERGYFEE Y N
Imalty rnphat Inthe person performance of mane"for hIcIt this tobcopemdthi chued.
1 shag ata employ any Peron In any rtunner at u to become ubj Y to the
w«kem•eenpen,atmn[resa(Ciluenla. Date WATER svBIEId/TRFAnnc PAID
Applica0 Z NOTICnt NEW RESIDENTIAL PLMB. SQ.FT. Date Recel til
Z O NOnCETOAPPLICANtheIf, ori m'Co teaa,tion ateof ExempteLahe
ahauld berme subtest to the Wanken'Coaperaatlen provbbu of the Lbor TOTAL
~ > Cede,you .),ed.forthwith mmpty with such provblam orthb perMt Wil be
� � � deemed cooked. BUILDING FEE
CLC CONS RUCTION LENDING AGENCY S I MIC FEE
I hereby affirm that them b a coutroctlon lending agency for the pedorn, ELECTRIC FEE
7 = anon of the workfor which thio permR b bsued Sec.3097,Civ.C.) TOT .:
U O Lender'.Name PLUMBING FEE
LL ~ lender.Add neaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1mrti(ythat l have read thbappllatbn and atatethat the a ffifom ion
bmr .lagrt tocomplywfthaUcLtyandrm,ntyordinanonandy tela , PERMIT1561JANCH FEES PAID:
r N relating tobullding coretrunlon,ard hembyauthodae repreaentativnofthb
I•" Z c"ytoenterupontheabo,e nth propenyfm Wpeabnpurpoas. AL'IERORADDTOI.ECH.
(We)agree to save,IwemNfy an d keep hamdm the City of Cupertino Date Receipt#
U agobet Wbilitim,Hdgmena,coatsaM expenses which my in anyway.. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agsjVQa��mnC.Yae�Ineconsequep{�of the gra�uing d thio pertnit.
AIRHANDUNGUNIT(OVER 10,=CFM) CONSTRUCTION TAX
Slgrature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA] RDOUS MATERIALS DISCLOSURE
Will theappliarrt e(uturc building ocevpant store or hard4 havrdous HEATING UNIT(FO 100,ODO BTU) Date Recei t#
material a dafired by the Cnpertiro Mu Nc"""Cade,Chapter 9.1Z and the
IfealthaM Safety Code Section 75532(.)7 I-EAnNGUNTT(OVERIDO,000BITn 10 a
❑Yee No ydaa�
Will the appu¢nte tune Wllding.P.rt use equipment«deviant VENTILATION FAN SINGLE RESID) 1�SP DATE
which endt havMous air conamina i,a,defined by the Bay Area Air
aIBm
y Management District? 13011YA-COMP OHPOR 100,0(t)100,0(t)RM
X991Yn ❑No !5
Favc read eadthhe h &amu rCode,S ren.M5 fib 5533under
and 25p5t .1 of BOILER-COMP(OVER tm,000 BTU)
the U rdlt Hefth6Safety Code,Sectbm25505,75533a,rt,tatIt OV )INu
urdentand That if the building don rotcarrently haveatenant,that library NEW ItH9 DEN77AL MECH. SQF7
reapoulblllty to notify the occupant d the requirements which oust be rnet Uf
prior to Lauante d.Cerllflotc o(0¢vpmy. rjw
Owner or authorired agent Dr4 TOTAL �r/ISSUED BY: %s.Irea
OFFICE COPY