22233 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro en Identification 7 PERMIT NO.
Building Add reg.�3i� ��
�-r 22233
�Cy17 one:
e_pAal6 K45-,9,/ jy^a_ 'CITY OFCUPERTINO-BUILDING DIVISION / ��
Contra era Nam¢: LIc.Nn APPLICATION / PERMIT �D —
AL T BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL X
Architect/Engineer. LIc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrese: e '41) l PEIMHISSUANC13 �.QQ
LICENSED CONTRACTOR'S DECLARATION 1:1 D LlJ
I hereby affirm that l am Leaned under provisions 0(Chapter9(commne- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Division 3 ofthe Business and ProfesslonsCode,and my
license is in full force and died. PANELS ..//��''
LlcenseCliss Lk.N R•e��(� le C.?
Date Contractor V
ARCHRECI.5 DECLARATION 701-1000AMIPS
97 I understand my plans shall be used as public records. OVERI"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Llcemai Professional SIGNSELECTRICAL 9 ALE D
6 OWNER-BUILDER DECLARATION M P U T E -
rii ,& SPECIAL CIRCUT/M15C
7 L,, owing rafifirm son.(hatlamexempt(roossa Contractors License law forth.
fo0owingreason.(Smion7 tw Business Proleesione ebyor
Or TLMP.METE9ORPOLE INSi.
cnystm mpriortol eracearo mqui theapli=tfmolbh, er ttr
Q any.tmdurepkartolbhat hail lice sed pursuant t the rovislhparmlte ]POWER DEVICES
K
fila a signed statement that ha t licensed pursuant it the pmvbl00) of the V
3w(-� Contractors License Gw(Chapter9(mmmendngwith
wmpt hemfof mmai d SWIMMING POOL ELECTRIC
BOJ "a da Budnenand Pro(esslordCode)Orthat hedexemp[therefromarW VALUATION
Q.•577 the'sae's for the alleged exemption. Any violation of Section 7031.5 by any OUTLE7SSWI7CHESFIXTURFS
applicant fora permit subjects the applicant to a civil penalty Meet more than
five hundred as
dollars($5D0). NEW RESIDENTIAL ELECTR SQFf. STORIES TYPECONSTRUCTION
yrs ❑I,as owner of the property,or my employees with wage as their rule
compensation, intended oroffendfor
C O sole(Sec 7094,to an ow and PMeperty Code:The C improvre esi hereon law
5$ don not apply ssuchtomownerofproughhisobullds or mploymproovided con,and OCC.GROUP RFS.UNITS
who dansuchwork himsslforthrough hieown employees,provided that such
improvemcnta are not intended oroffered forssle.If,however,the bulldingor TOTAL: .06
Improvement is sold within one yearofcompidlon,the owner-bullderwill have
thehurden of proving that he did not build or Improve for purpose of sale.). QTy, PLUMBING PERMIT '"IP.` FEE FLOOD"LONG APN
u L as owner of the pmperty,am exclusively o.,,with..¢need PERMIT ISSUANCE
to construct the project(Sec.7094,Sundries,and Pro(essiom Code:
The Contractor's Limine law does net apply to an owner of property who ALTER-DRAIN VENT-WATER(EN
ba Bds or improves thereon and who common,for such pAM ojewith a
cott{aaorta)Encased pursuant to the Conlnctora License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
•
OUTSIDE FITS
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N RECEIVE#
WORKMAN COMPENSATION DECLARATION MIXTURES.PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificate of consent to copy
ythereo ora RECEIPT M
certificateC(Workeri Compensation Insurance mecertifled copythemo((Sec. CAS EA.SYSTEM-1 RICA OIETLETS PARK FEE Y N
Pcil3800,Lab C.)
Com an RECEIPT
GAS EA.SYSTEM-OVER 4(EA)
Y BUILDING DI VISION FEES
edl0ed copy is hereby furnished.
certified copy is Ilea withh the city
Inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ry
CERTIFICATE.OF ExEMPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA,SFT. Date Rctmi t#
(I' eectlob need no[be completed lithe permit b moons hundred dollars
($1 I0)rtorJ WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
]certify ifytthatmthe performance ofthe work forwhkhthle pertnit le WON,
[,hall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Worken'Cmopenwtionlawsof CxIfernla. Date PAID
OZ Applicant Date Rewi tit
Z 0 NOIICETOAPPLICANT:lf,afermakingthd Certificateof Exemption,you NEW RESIDENTIAL PLMS.__SQFf.
Hshould become subject to the Workers'Comperoation provisions of the Labor - TOTAL:
= N Code,you mu at fort hwith comply with such provhlom or this permit shall be
> deemed revoked. BUIL12ING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
(hereby affirm that there is a construction landing agency for the perform ELECTRIC FEE
7 _g
Z ance ofthe work for which this permit be bsoact(Sm.3097,C1v.C.) TOTAL:
e) O IarWerb Name PLUMBING FEE
U. I— Lemier.Aadress QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
OW Icertify that l have read this applicationand datethatthe above information qq
(1 Is cored.l agreeto comply with all city and county ordinances and date laws PERMIT ISSUANCE Zr 09/ FEES PAID:
>. W relating to building construction,and hereby authorize representative.ofthls
F oned property for inspection purposes. ALTER OR ADD TO MECH.
Z city to enter upon the above men/iDate Re[ei t#
_ Agaimtlb
mnlfy an d keep harmless the City of Cupertino
}adgmenb, rad ezpencesw c mayInanywayaceme AIRFIANDUNC UNIT(TO]0,000CFM) SU$TOTAL•
In conaeryence of granting thispermt.
—7—
9 MR HANDLING UNIT(OVER 10,"C F) fEp CONSTRUCTION TAX
reo pliant/ tractor Date IXHAUSTHOOD(W/DUCT) a,Q CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS URE
Will the applicant or mmrebulldingoccvpantstere o ndlehazardous BEATING UMTTED100,00011M UO
material a,defin¢d by the Cupertino Municipal Code,Cha 9.1$andthe Date Recei [R
liealih and Safety CoQSyet9on 2553](x)7 HEATING UNIT(OVER 100,0110 BTU) . S—
s 171Yn of,SA '
TOTAL:
Will the applicant tore building occupant use equipment or devices VWEILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousab cont.mi...defined by the Bay Arca Air � y�
Qv Itty Malugemcnl Dlatk BO[LER-COMP pI-I'OR 100,IXD BTU) kk!!
Y. o
• 4havereadthehoz ous terlalsrequlnmenbunder Chapter G95of BOILER-COMP(OVER 100,000 BTU) t/ In t
the Calficriahlnith C e,Sedions25505,25533 and 25534. I JUN
TJ
understand that lit ullding om not currently have a tenant,that it is my NEWRPSIDGNTIALMECH SQ.PT.
rospordbil on fy the note Imnmotswhich.dhcmd
prl cc a cateofo.pancy. fish, a at M'wdahW
nero authml d agent - Dat¢ 7 141�L X16 v��N�/ /
TOTAL: J b S ISSUED BY..
OFFICE COPY