22338 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro act Identification PERMIT NO.
Building Address: O�'� 'So• �d - - - 22338
t_nvrer.Name: one:
A
CITY OF CUPERTIN0.BUILDING DIVISION O
APPLICATION / PERMIT lD-1-co^� .
BUILDING-ELECMCAI PLUMBING-MECHANICAL CATEGORY CONTROL N
ArcM1ItM/Engineer: ' r�.yy /(1 LIc.IJo:
�C C1'1 Y✓KfY� QTY ELECCRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I L [:] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.aRlrm that am licensed under provisions of Chapter9(ccermane. APPLIANCESRESIDENTIAL JOBD RB'f10N
Ingwltb Se tOR700D)of Divisim3ofthe Businessand ProfessimsCode,and my
license Is in full force and effect. PANELS -d `
,
License Class Lich �
Date Contractor —UP TO 2DOAMPS
ARCHITECTS DECLARATION 207.1000 AMPS
{ppP+++roti OC I understand my plana shall be used as public records. OVER I"AMPS SQ.FT.FLOOR AREA -aS/SQ.Fars.
E z U Licensed Professional SIGNS EL L
G�6 OWNER-BUILDER DECLARATION SPECIALC CUI /
Zt, y I hereby affirm that l am exempt from the Contractor's License law forth.
0 R p q following reason.(Section 70115,Business and Profealm.Code:Any city or 'FFMP.M
p� cauntywhichmquimsapermlttomwtmd,alter,impmw,dennllah,orrepair
Q anystm=m pdorwits Issuance,also requires the applicant forsuch permitto POWER DEVICES
r U file a a1gnM statement that he is licensed pursuant to the provisions of the
3µk. Contractor's Llcenu Law(Chapter9(commencing with Seakm 7000)of Divi-
oSWIMMING VALUATION
F,RIO"J eln3ofthe Buslneaand Professloru Code)orthatheis exempt therc(romand ��s
a.•]] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES v.-(/ II ,�.))
$!ay
applicant!orapermibubjectsthe applicant ins civil penalty ofnor more than l l� 6 2,w
five hundred doll..(5500). NEW RESIDENTIAL ELECTS Gl �n I,as owner of the property, SQ'FT. ' STORIES TYPECONSIAUCTION
❑ p perty,or my employee with ween as their sole
C
mmpenatim,wflldothewwkandthestm=mbnotintendesLimoffered
5�O ale(Sec.7044 Business and Pm(mlov CCade:The Contndols Llave ltaww
doe not apply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNDS
GG who does such work hlmxl(or through his own employees,provided that such
improvements ammtintendedoro(fe.dforuk.ILho mepthebulldingor TOTAL; s
improve menthwldwithlnoneyearofcomple11oktheowner- Hderwillhave
tlgkurdanofproving that he did not build or improve for purpose ofuk.). QTY, PLUMBINGPERMIT FEE
IUJ Las owner of the property, FLOOD ZONE APN
p perry,amexclusivelyessndlngwbb sCodd PERMITISSUANCE
contnctontoconsithe project not app! to an o and of pro om Code:
Tbe Coor imprsasthereon,
License Lew doe cad apply tow owner of properly who ALTER-DRAIN A VENT-WATER MA)
builds ar Improve thereon,and who t.d e. for such plojede with• FEE SUMMARY
c ctor(eexempt under Snt m
the Contndo/a License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this mason
Owner DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y— N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have s certificatese
of consent to self-insure,or• RECEIPT N
cdifluteofWorke.'ComNe timisuunncemamrtlfledcopythereof(Sw. GAEA. INCA OUT PARKFEE fS Y N
3300,Lab CJ S RECEIPT N
Polity N GAS EA.SYSFEM-OVER 4(FA)
Co. an BUILDING DIVISION FEES
erti0ed copy is hereby furnished.
CortiGRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHE N�
❑ fied copy Is(fled with
the the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP P D
NCE
COMPENSATION INSURASEWER-SANITARY-STORM EA,2001rr. l BIC Re 1 t#
CENssectian need not be completed B the SURA ls for orae hundred dallan
($100)or less.) WATER HEATER W/VENT/ELECTR IEhRGYF
I certify that In the performance of the work(orwhlch this permit la blued, —
I shall not employ any person In any manner w as to become subject to the WATER SYS"177.1/T•RFA.DNO
Wor1vmVCompenation Laws Of California.Date PD
O Z Applicant NEW RESIDENTIAL MB.__SQFE. Dale Recei t#
leof
Z O NOTICE TO APPLICANT:ILafter making this CertiflcaExemption,you
sbwld become subpct to the Workers'Compessallon provisions of the Labor /TOTAL:
cN Code,you at forthwith comply with such provlslou or this permit shall be x
W j deemed revoked. BUILDING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there is a croutrudion lending agency for the perform- ELECTRIC FEE if
D Z an.oflhe work for which this permit is Issued&c.3097,Civ.C.) TOTAL:
V O Lender.Name PLUMBING FEE
LL F Lcndcr.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL '
OW Icedilythat I have readthkappllcationand state thattheabove Information a�
1 lscormd.lugreelocomply with all city and county ordinances and&ate laws PERMFT ISSUANCE ' h FEES PAID:
�. N relating to building construction,and hereby authorize representative ofthis ��yy
F Z city to enter upon the above,mentloned property fon lrupectlon purposes. l ALTER OR ADD TO MECH. �ls�o Date Recel t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,matsand expenses which nuy In an way amus AIR HANDLING UNIT CFO IQODD CFM) S BTOTAL'
seal City In mno�eaOro Of the ng of this p rplB
a/'lnl T AIR HANDWNC UNIT(OVER I0,000CFM) CONSTRUCTION AX
'Igutre of Applicant/Comracior 19.te, EXHAUST HOOD(W/DUCT) CONSTRUCTIONT XPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTI. Date . Rece #
material as defined by the Cupertino Municipal Code,Chapter9.12,and the
I kallh and Safety Code Sacilm 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No
Will the applica in or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanrdous air contaminants as deEned by the Bay Area Air #,a
Ility Management IMtrict2 BOILER-COMP 6HPoR]BO,000U)
BT
1 I Ye No
have read theFazar ossa malerlala rcqulrcments underChapter 6.95 of BOILER-COMP(OVER 100,0008N) .N�Sa q
the California Health k Safety Code,Sections 25505,25533 and 25534. I JUL V 198,
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MF.CH SQ.Frmapop"a4k
priori Issuance
ofnota y the Certificate
ant ofOcfthe requlremenb which must be met
prior to Issuance ofa Cerlifkate ofOaxupanry. �L a�y��y��ss��� �(`[rAy���D�s►'J
Owner or authorized agent Date TOTAL: ISSUEDBY:
l
OFFICE COPY