22662 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIBLMIT NO.
Building Address: / 22662
0 Llqo 04k 1/1
A
CITY OF CUPERTINO-BUILDING DIVISION p �
Ca�nso-atta,aN.me: LIeNa: APPLICATION /PERMIT
�Rrl JDA �((.a-K3/Kf le1G'YSG BUILDINGF3.FLTRICAL-FLUMBINGMECHANICAL CATEGORY CONTROL
Architect/Frgineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE El ❑ ElLICENSED CONTRACTOR'S DECLARATION
Ihereby affiren But l am licensed under prmBdpnaf Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB OESCRA'FION
Ingwith Section 7000).!DiW.lon3.fthe Businessand I'ro(essionsCode,and m ,
liccnsa ism full form and died,
Date L ' • n . PANELS
LiceneCUas�i Lic.N /
Cmftra � lS .�VLJ�IOT�\!+rC•I•.[S'>
l�P,
20140DOA.MI'9
ARCHITECT'S DECLARATION OVER 1000 AMPS SQ:FT.FLOOR AREA
ONO Iunderstandmyplans.fullbeused so public records. L E D I IV
Licensed Professional SIGNS ELECTRICAL
�CtkC�' OWNERexNLDERDECLARATION
In• G SPECULCIRCUI7/MLSC
s' � owing reason.(Section hat 7031Z,
031 rept(romthe d Pmfcwio License LawAny dt the -
D�F@ followinhich re uiposaermutt cosinea andr,impr tom Code:Anytltyor TEMP,MLHiRORPOLEINST.
�4g� rountywhirepHorrelft e a cl alwmqu, stheaprove,dersuch,orto
G 6 any swtturc statement
at to,e,abp sed pursuant t the
provisions
ofpermit e POWER DEVICES
file a Cmdrsigned rtatement that ha is IloenaM pursuant it the Eon 7000) of the '
^30�' slon3 ofthe Buiainessad Professions Code)orthatt hely Sectlontherefrommnd - SWE.1MIIv'G POOL ELECTRIC VALUATION '
5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCHESHXTURES
O
applicant fees permit.ubjacta the applicant to a civil penalty of not room than
five hundred dollars MOO). NEW RESIDENTIAL ELPGTR .PT. STORIES TYPE CONSTRUCTION
�j? � erty
1,as owner of the prop ,or my employees with wages as their sole
compensation,wBldothewark,and thestrutture Isere intended or offered for
k N p sale(Sec.70WL Busines and Pro(esalom Code:The Contradoes License law
� $ doof f apply to an owner property who Wilds or improves thereon,and
s^ cs who doessuch work Menselforthraigh his own employees,provided that such OCC.GROUP RFS.UNITS
Improvements are not intended proffered forsals.If,howevep thebullding or TOTAL:
Improvement issold withinoneyearofcompletion,the owner-Wilderwill have
th _IIurden of proving that he did not build or Improve for purpose o(sale.). QTY, . PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
roniracion to construct the project(Sec.7014,Bush.and l'ro(esviov Code: - '
The Comrattor'e Licerue Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or Improves thereon, and who contracts for such projects with a
cQtLt(actor(.)licensed pursuant to the Contraction'.Ltrnnm Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
tri am exempt under Sec. B&P C for this reason - -
OUTSIDE FELS
DRAINSFLOORRODF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FI)(7lIREC PER.]RAI' SCHOOL TAX Y N_
^QI hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT N
cenifioteofWorkers Compe timinauranmorattdifkdmpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.) RECEB'fp
Policy p any
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FE FS
'
amMCekiflcd copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Data Receipt1?
(fhb section need not be completed lithe permit isfon one hundred dollars
($100)or In..) WATER HFATERW/VENT/EI.ECTR ENERGYFEE Y_ N
I mrtify that In the performance of the work for which this permit Ia issued,
I shall not employ any person In any manner so as to become subjpet to the WATER SYSTEM/TREATING Workers Compensation Taws of California.Date PAID
ZZ Applicant NEWREEIDENHALPLMB. SQ.FI'. Date Reeel IH
Z O NOTICE TO APPLICANT.If,after nuking t his Certificate of Exemption,you
Fshould becomeaubject to the Workers'Compensation pmvisiom of the Labor TOTAL:
ir W Code,you most forthwith comply with such providers or this permit shall be
BUILDING PE'
W E3
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d G I hereby affirm that there is a ocru uction lending agency for the perform TOTAL: ELECTRICFEE -
Z an.ofthe work for which this permit is issued(Sec.3097,Civ.C.) PLUMBING FEEV 0 Lender.Namc
Cz
H Lenders Address QTY. MECHANICAL PERMIT FEE
LL O W MECHANICALFEE
Imrtlfythatl have readlhisappllotionand atatethatthcabove ln(prmation
bcomd.I agree to complywith all city and county ordinances and state laws PFRMITISSUANCE FEES PAID:
N relating tobuildingoom uctlon,and hcmbyauthorlurcppmrmativnofthis
city to enter upon the abovo-mantloned property for Inspection purposes. ALTIRORADDTOMECH.
? (We)agree to save,indemnify an d keep harmleas the City of Cupertino Date Receipt#
V against liabilities,pdgerents,"sand expenses which may In anywayaccrue AIR HANDLING UNIT 17010,000 CFM) SUBTOTAL:
agairot said city in consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER iQ WOCRf)
Signature ofApplicant/Contract.r Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Will the a lion or future building occupant store or handle hazardous HEATING UNIT(TO 100,!100 BTU) _
material as defined by the Cupertino Municial Code,Chapter 9.17,and the _ Date RCCCIpt#
Ilealih and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BM TOTAL: G
M'Yn []No
Will theappileaM or future building occupant use equipmem or devices VENTILATION FAN(SINGLE RESID) ISP DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Mawrt gerrrDistrict? BOILFR-COMP LIHP OR 100,OD BTU)
4 Yes I�No
have read the baaa ou.materials requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) X41M� V �,yy1
the California I Icalih&Safety Code,Stolons 75505,25533 and 25534. 1 wII
understand that if the building don of currently have a tenant,that it is my NEW RESIDENTIAL MEC!{. SQ.FT.
reepomilulity to ndilythe occupant of the requirements which at be rrrt - K W
proneoz auoonce fac�pll ateof Occupancy.
lhorlu agent tom— —�Date� ISSUIiU Bye's
TOTAL:
OFFICE COPY