22230 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEfkMlTNO.
edin o Narzrr� W�� lV,5 22230
�U —r— �/ one: p
;;Wla5 f� L /Uf ?37.309 CITY OF CUPERTINO-BUILDING DIVISION _ p
G/ggyra QGEw� �SNo: APPLICATION /PERMIT �l
"^ BUILDINGFl =CAI PT_UMBINGMECHAMCAL CATEGORY CONTROL p
Architect/Engineer: Lk.Nex
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO.
Address: PERMITISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pewWons of Chapter9(mmmenc APPLIANCISRESIDENTIAL LOB DESCRIPTION
ingwllh ief.1170(0)ofdeffeon3o(the Buslncssand Pro(esslomCode,andm D \ _(-> �
E.gwft isc fullformanddfed. PANELS Y1c%rr�s9CV
Limose Clam Lk.#
Date Contractor —UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000AMPS
q�q�ut o ZCC I understand my plans shallbe used as public records. OVER 1000 AMPS AR N 5/.Q.FT.
k 4 U Licensed Professional SIGNSELECTRICAL �5��s8 1�
<<< OWNER-BUILDER DECLARATION [../ y C
`!n]Fn SPECULCIRCUIT/MISC A V G
I"' 7 owingyaffirm that l am exempt from the Contractor's License Law for the
0V. (ollowing reason.(Section 7031.5,Bualnessand Profession,Code:Any city or TEMP.METER OR POLE INST.
�5.uq county which requires a percept.construct,alter,bnprove,demolish,ormpalr,
e� .� DAIE
anystmdumpdortoitsbsuance,eborequirestheappBuntfwwOpermitto ]OWER DEVICES YLL[ L
file a signed statement that he is licensed pursuant to the provisions of the
3 ce Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O ,ion 3 ofthe Businesaand Professioro Cods)mthat he b exem therefmnand
a o the basis far the alleged exemption. Any violation of Section 7RTS by any OITILETSSWITCHESFIXMRFS Q 00
ya 666 applicantu fees permit subjects the applicant toa civil penalty anmore than
�y five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. S10WES IYPECONSRUCTION
O m ❑I,as owner of the property,or my employees with wages as their sole
C 74.< compensation,will do the work and the structure b not intended or offered for
SFO vie(Sec.7004,Business and professions Code:The Contractors License Law
�j $ does not apply to an owner of property who Wilds or Improves thereon and OCC.GROUP RFS.UNITS
who does such work hlmxlf orthrough hi employees,provided that such
improvements are not Intended proffered for.xle.If,however,thebullding or TOTAL:
Improvement Issold withinuneyearofcompletian,theowner-builderwill have
t reen of proving that he did not baud or improve for purposeof.le.). QTy. PLUMBING PERMIT FEE
ELDDDwN'E APN
I,a,owner of the property,am exclusively lBusi Business
and
ding Prowith ns Ccdd PERMIT ISSUANCE
contractors to mmwn the project(Sec.apply
Businessand of property
Code:
The Coor irepr's License Law don not apply et an owner of property who ALTER-DRAIN&VENT-WATER MA)
Wild,or improves thereon, and who tmdm's (w such . with a FEE SUMMARY
oq¢t.[+dor elicensedpursuant to the Contndor's License Law. BACK FLOW PROTECT.DEVICE
L-J I am exempt under Sec. B&P C for fhb reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECFRTp
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOL TAX Y N
711 hereby officer that 1 have a mrtilate of consent m se6-inwre,ora RECE91T N
certificate of Worlun'Composedionlesumitee ora certified copythereof(Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
3800,lab C.) RECEIPT p
Policy p GAS EA.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEES
CeAllied copy b hereby fumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E]CeAified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT.
(fhb section need not be completed lithe permit b for one hundred dollars Dale Recei t#
(SIW)orlcm.) RIOTER HEATER W/VENT/ELFLTR ENERGY FEE Y_ N
certify _
1 rtify that in the performance b ce of the work for which this permit muted,
1 shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TRFAMNG
Workers Compensation Laws of Califomia.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB._OFT.
PDate Remi t#
Z O NOTICE TO APPLICANT.if,cher making this Certificate of Exemption,you
CC
should become sub}'ct tothe Worken'Comp nsaton provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING I.
j devoted revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby aflim that there is a construction lendingagency for the perform- TOTAL: ELECTRIC FEE
Oante ofthe work for which this permit is Issued CSm 3097,Civ.CJ
I<nder,N. PLUMBING FEELL I- lender's Adders. QTY. MECHANICAL PERMIT FEE
LL U lomifythatlhavereadthbappliatio..rulaatethattheaboveinformation MECHANICAL FEE
O W Jammed.Iagreetocomplywithalldtyandountyordinannsanda.teiaws PERMIT ISSUANCE FEES PAID:
} a relating to building mmtroction,and hereby authorize rvpraentativn of this
N d1 toerwru et cabove- tetloned forW inspection x,. ALTERORADDTOMECH.
H z r Property h WTo Date Receipt#
(We)a to u In e 1 p harmivss the Clty of Cupertino
V against 'a ieApdg n a xpensn which ma in any wayacaue AIR HANDLING UNIT(fO 10,1700 CFM) SUBTOTAL:
.gat . d ce ins of this it AIRHANDLINGUNIT(OVERIO,00)CFM) CONSTRUCTION TAX
SI atom of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building va
t store or handle hardous HEATING UNIT(TO IDgM 000 R
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ DatC Rip
L# P(_
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) ,,P AL: 1 JL
❑Yea ri No ,,
Willtheappliant orfoomelnildingoaupantuseequipirent ordevices VFNIRATIONFAN(SINGLERFSID) ISSUANCE DATE
which emit hazardous air contemirunrsas defined by the Bay Arca Air ���
Quality Management District? BOILER-COMP OHPOR 100,0!0 BIIn f! .(
40Yes 1F��No u
. haversadtheh. lusmaterials requirements under Chapter 6.95of BOILER-COMP(OVWR100,000 BTU)
the California Health&SfetyCode,Sections 75505,75533 and 25534.1 'H=d"Ii�tl
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT.
rnponsibilitytonatifytheoccup.nt oftherequlrarenlswhichmustbemd
priortoiuusemofa Cerificateof Ocmpancy. /\��-/]
Owner or authorized agent Date ISSUED BY
TOTAL:
OFFICE COPY