22600 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-.
Building Project.Identification F PERMITNO.
Building Address:
- . 218SZ OwcVICW 22600
rers acre: one: AFFLIkA HUN 9U9qnTA-[bTTC-
F-DLLFIN W. 6PLOWN E CITY OF CUPERTINO�BUILDING DIVISION
c.no-ad.r.Name: ,gyp ' - u=' .: APPLICATION / PERMIT
CON I SID W 37j �(JBUILDING ELF MCAI PLUMBINGMECHAMCAL CATEGORY CONTROL M
Architect/Engireer. Lk.No:
_ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmss: Qr7.OOX 6 If G SG .�,,,j�. �q 5161 s Ill MMI FLUMB slk�ft
PERFIITISSUANCE
LICENSED CONTRACTOR'S DECLARATION -
Ihereby affirm that l am licensed under provisions of Chapter9(commem. APPLIANCESRFSIDENTIAL JOB DESCREx110N
Ingwlth Sed(on7000)of Division3.fthe Businemand Professions Code,and my -
liunsebinfull(o sand c.al /r^^ PANELS
License Gla LION 3�3 r�M1all - `/ •Se-w e t
Date ContractorUP IQ 2DUAM
ARCHITECTS DECLARATION 201-1000 AMPS
qna 7 I understand my phim shall be used m public records. OVER 1000 AMPS SQ.FT. AREA S/SQ.FT,
Fi Fj Licensed Professional _ SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIXCUIT/MLSC
7 '�a I hereby affirm that I am exempt from the Contractors License Law for the
p following reason.(Section]m1.g,Business and Pro(eml...Code:Any dty.e
OZI: TGMP.MEIER ORIOLE INST. r -
F,M .countyclum requiressp antoconstequi theapliunt frsualsprmpaireratto ,
�ysany swnuretatementa issuance,alsosed Pursuant t the provisions
of to POKER DEVICES -
K file a signed easement that he b licensed pursuant it the proWsions f the
�$ Contractors License law(Cha 9,CWa).rtha Section lM((fi Divi-
Man 3of the Buancu and Pro(evl.ns Code).rthaBhebexemptthere(romand SWIMMING R70L ELECTRIC .
Sn�, the basis for the alleged exemption. Any violation of Section 70315 by any
¢ OUTLETSSWTTCHESFIXTURES' '
five hundred
u
applicant permit subjects the applicant to a civil penalty of not more than
�.. five hon s owner
lars ofthe pro '
I,as owner of the property, NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION'
7 ❑ p ork,and
or my employees with wages as their sok
compensation,wllidothe work and the structure Is no[Intended or.Beed for
,/ p sale(Sec.does not a ppy Business and Professions Cade:The or impnMs Wcmem law
q5$ whodoesuchly oanownel ofthroug property who
nemparimprorrogand OCC.GROUP RES.UNITS
whodoerne diwork himself ed.rough Msowne.If,ho es,however,
theprovided that such ,
Impmvemcntsa ld intendedoroofcco orsale.theo vegtflderwdln ve TOTAL:
Improvenrnt Lssold withinoneyxarofcompldion,theowner-bunderwlll have
to Nen of pawing that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
1,as owner of the property,am exclusively contradlog with licensed
adec PERMIT ISSUANCE b
• niraa.to construct the project(S70K Businex and Professions Code:
The Contractor's License law docs nor apply to an'owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves theme.n,and who coraracts for soon pwjeas with a FEE SUMMARY
ondarts)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
1541amexempt under Sec. B&P C for this..an
OUTSIDE ITES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner DateRECEIPTN '
WORKMAN COMPENSATION DECLARATION
F11affirmpD(.NRE,q PER TRAP SCHOOLTAX Y_ N
1 hereby affirm that I have a a certificate of consent to sema
lf- re,ora RECEIPT p
cenBlcata.(Workeri Compensatle.insurance ora certified c.pythere.f(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
33000,.b C.)lley a— Va +.0 . - RECEIPT
Com any GAS EA'SYS<EM-0VER4(EA) BUILDING DIVISION FEES
ECertlfied copy he hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
❑Certified copy b filed with the city inspection division.
CERTIETCATEOFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANRARY-STORM EA.200FT. .U Date Recei t#
(Thlssection need not be complctod if the permit b for one hundred dollars
($1W)mless.) - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I mrtlfy that in the performance of the work for which this p permit is Issued,
I shall not employ any pe In any manner sit as m I / to the WATER SYSTEM/TREATING PAID
Workers Comperlvtlpnla of�}Ilfornla. Date
—
zZ Applicant R,lX ri __W w`-r - NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tN
Z D NOTICE TO APPLICANT.If,after making I his Certificate of Exemption,you
should become subject to the Workers'Compensation provisitemp"I Labor TOTAL:
CC Code,you most forthwith comply with such provisions or this permit shalt be
BUILDING ••E
W > deemed revoked.
a O CONSTRUCTION LI LADING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform - TOTAL: ELECTRIC FEE
Z ance of the work for which this permit isissued(Sec.309],CIv.CJ .UU
V O Lenders Name PLUMBING FEEU. •6y
H Lender.Address QTY. MECHANICAL PERMIT FEE
O W Iurtilythat l have mad this application and stasethatthe above information MECHANICAL FEE
C bearrcd.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authom,a representatives of this
N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,ydgments,costs and expenses which may In anywayaccus AIR HANDLING UNIT(70 10,000CFM) SUBTOTAL: ,O
agaimtsaid Cityln aroma a ofthe granting ofthis permit.
a+ D_. T'/ - s(I �� AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCFIONTAX
Sigmuturcof Applicant/Contractor I Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hsvamlom HEATING UNIT(TO 100,OD00TTh Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
IkaithandSafety Code r�Section ZS532(a)? - HEATING UNIT(OVER 100000 BTU) TOTAL: ,�QD
FF�''�I Yes - rW No
TVllltheapplio rat or No brilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISWA (i$DATE
which emit hamrdom air contaminants as defined by the Bay Area Au CA1
Quality Management District? BOILER-COMP PHPOR 100,0(0 BTU)
YesIo
esAt
4have
mad the haar7)Nmaterials rectulmers,nts under Chapter 6.95ot BOILER-COMP(OVER IOD,000 BTLJ)
•thevuf.miaHesbe&SafetyC.de,s io.2SWS,25s33.nd2SSU.I — A }
understand that if the building does not currently have a tenant that it is my NEWRESIDENTIALMECH. SQ.FT.
responsibility,to notify the occupant of the requirements which most be met /1jNsN w{nabajeM
primt.iss ance.(. rtlficatcof Occupancy. Y1�W,V4INY Wls1 -
4 11
Owner or auth.dud agentDate TOTAL: ISSUED BY. V
l
OFFICE COPY