22263 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMITNO.
Building Address:
'97K .22263
2�be (�los5'or,,
wnera ossa: ne: A p
� T{�rrn 60e_5*� CITY OF CUPERTINO-BUILDINGDIVISION
cono-an (y/p Lm.No: APPLICATION I PERMIT - h
BUfLDTNG-ELF MCALPLUMBING-MECIiANICAL CATEGORY CONTROL
Architect/Englruer. Lie No:
.QTY ELECTRICPERMIT FEE BUILDING
UILDING PERMIT INFO
Add... - PERMIT ISSUANCE 00 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under peovlsions of Chapter 9(commec APPLIANCES-RESIDENTIAL IOBD RII'1TON
Ingweh .full for.
o(thegu.lncesand Pro(nelonsCode,and my —'
license o In full lone and effect. PANELS
License Clans Lk,N
Date Contnc[or
ARCHITT.CPS DECLARATION NI-I"AMI'S
rc0 O I understand my place shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA -1 $/SQ.FT.
!i� Licensed Pnefesowal STGNSELECTRICAL
�6g OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
I herebyafBrmthat l am exempt from the Contractors License law for the
ZO Ho,2. following reason.Section Code:
ion 7m1.5,Business and Professions Any city or Tppp METER ORPOLE IN
p i" county which requlrcsa permittocoretrut,alter improve,demolish,orrcpalr
a anystruccom prlortolts issuance,also requirealhe applicant forsuch permit to POWER DEVICES
U file a signed statement that he It licensed pursuant to the provisions of the
0 IN
Contractor's License Law(Chapter 9(commencing with Section 7000)of onDivi- SWIMMING POOL ELECTRIC ALUATION
F,�Oa tl3o(Ihe Business Pro(eareb
laCode)orthet he
a.•11 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETS &
SWITCfSFU(TURES c CM
applicant for a permit subjects the appNeant to a civil penalty of not room than �i
five hundredsownerla.ofthe property,%. NEW RESIDENTIAL ELECTR SQF7. STORIES TYPE CONSTRUCTION
❑I,asownerll thedo e woand
my empWyenwith wages their door
compensation,Business and
pr andthe semcWrels redIntended or License
d for
Law _
q sale(Sec.70Kpply to Business of
Code The Contractors Liceree law
S does not apply to work
owner of property who n lids or Improves thereon,and U D LNHs
who does
mentsa not men ort orough hleownemp,hownwr,the building
ildinhat gch p UTE R
Improvement.red w:thmone earofoomplr offered tlo If,hrwevegtheerwiil have TOTAL: L C
improvement I,sold wllhinoneyrarofcomplellrn,the owner-bullderwlll have _
thtJZurden of proving that he did not build or improve for purpose of sale.). QTY. : PLUMBING PERMIT FEE.t FLOOD ZONE T4 N
U I,as owner of the property,am exclusively contenting with IlunaedpE( )T ISSUANCE DA E
contractors to mestruct the project(Sec 7044,Business and Professions Code:
The Contractor's License,law don not apply to an owner of property who ALTER-DRAIN VENT WATER(EA)
W Illroves s or impthereon,and who co -
contracts for such p(o)ects with a -
coator(s)Ilcersed pursuant to the Contractors License Law. FEE SUMMARY
6I am exempt under Sec. B&P C for this meson gpC)(pfOW PROTECT DEVICE
DRAINS Ell ROOF,AREA,COND. SANITARY Y N
Owner Date RFiCER'1'#
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOLTAK Y ' N
hereby affirm that I have o ld mese of consent m eel!-insure,ora RFE&T N
3800,LxeC.Worker%Compereatlonlreurance oracrtl(kd ropy thereof(sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380Q Lab C.I
Polity M RECEIPT
Cam GAS EA.SYSTEM-OVER 4(FA) BUILDING DI VX
ISION FEES
edified copy is heed with the
CREASE/INDUSTRL WASTE INTERCEPTOR' PLA ICFIECK FEE�rt
Certified copy is filed with the city Inspection divitlon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID —I 1 COMPENSATION INSURANCE SEWER-SANITARY STORM PA 200F1' DRIC R 1 Ifl
(rhlssetirn need not be completed Lithe permit ls for one hundred dollars
($100)arless.) WATER HEATER w/vENT/ELECTR ENERGY PEG Y
I cedifythat in the Performance of thework forwhlch this permit is useed, —
I shall not employ an/person In any manner ro as to become subject to the WATER SYSTCM/TREATING
Worlumv Compensation Lamof Callfomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMIL SQFT. Date CCCI tlf
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
F2should become subject to the Workers'Compensation provisions ofthe Labor OTAL:
fA Code,you most forthwith comply with such provisions or thin permit shall be O.p
deemed revoked. N a
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyeM that them a construction lending agency forthe perform TOTAL:
ELECTRIC FEE
-7 Z anceuf the workfor which this permit is Wood 15cc.3097,CIv.C.)
00 Lender's Name PLUMBING FEE
LL H Lender's Add.. QTY. MECHANICAL PERMIT 'FEE MECHANICAL FEE
O W Icedifythatl)uvemadthbappliodonandetatethatlheabove lnfomuit.
IL Escorted.lagreetocomplywlth allcityand county ordinances and statelzws PERMIT ISSUANCE FEES PAID:
'} relating tobuilding construction,and hereby authodze representative oftho,
F Z city to enter upon the above-mentioned property for inspection purpose.. ALTERORADDTOMFCH. DBIe Re 1 9fl
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
agamed liabilities.judgments,ones,and expenses which may in anywayamue AIR HANDLING UNIT(T010,000CFM) SUBT TAL'
ago fret Id Ci In con ma( a ofthiepennit.
�_-�T AIR HANDLING UNIT(OVER 10,"CIM) CONSTRUCTION TA
epqareof AppB Contactor a'v Date EXHAUST HODD(W/DUCT) CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllcan1.1 hours building occupant store or handle hazardous HEATINGUMT(TO100,n00BTU) Date RCC ' IN
material ass defined by the Cupertino Municipal Code,Chapter 9.17,and the
I1.1th and Safety Code Section 25532(2)7 HEATING UNIT(OVER 100,0(10 BTU) TOT
Yn MN.
Will the applicant or futum building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hamedous air contaMvnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR l00,IXD BTU) j
4 Yea Q No
have read the
cslth& fMyua Cede,ls Sections 2555,2553 and255M. I5o! BOR.FR-COMP(OVIR 100,000 BTU)ko P-
the de.tCalifornia Flralth& ildi.Code,Sections Flyh.25533and2S539. 1
undentandthat notify
the occupant
not erequi meats hick that it 9my NEW RESIDENTIAL MFCFi. $Q.FT }!�
mporelb0itymnotifythe rets f of the rcqulrcments which most be met
prior to issuance ofeCedlflcate of Occupancy. ;
Owner or authorized agent Date ISSUED BY.
OTAL:
OFFICE COPY
ADDITIONAL PERMIT' EES '
BUILDING PROJECT I DENTI FICATION - . VALUATION
ewLmxc
A"' -
PAVE
xAME FEE SUMMARY '
CONTRACTOR E BUILDING
NAME
lua xD. PLAN CHECK
r.DNTRACTORs FEE
PHONE 'SEISMIC FEE
CITY. ELECTRIC PERMIT FEE " -
' OUTLETS-SWITCHES-RECEP. ELECTRIC
LIGHTING FIXTURES - •PLUMBING /4L00APPLIANCES RESIDENTIAL ',
PANELS. - MECHANICAL
_SIGNS.
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
PERMIT VALIDATION
EMP.METER_OR POLE INS. I'
MOTORS 'BE E FEE SCH: '��uV4V C{
SERVICE CHANGE
Z 2
0 '.
TOTAL
. 1)_ N.. ISSUANCE DATE
LU,> CITY. - - PLUMBING PERMITr FE RLOG. ELECT. PLG. MECN.
d S,
Z ,[ ALTER�DRAIN&VENT-WATEWMA.I,. �` O'
U O - BACK FLOW PROTECT.DEVICE
LLU ``' DRAINS.FLOOR„ROOF,AREI COND., P�D
O�a FIXTURES-PER TRAP -
” GAS-EA.SYSTEM•I INCA OUTLETS
U - GAS-EA.SYSTEM OVER 4'(EA:)
INDUSTRIAL WASTE INTER. - '(�E.�(/tywjE•
LAWN SPRINKLERS 1INC 5 V.B. �V �K W{IW 417N
LAWN SPRINKLERS-OVER 5(EA.)
SEWER;SANITARY-STORM EA:400fI1 -
WATER-HEATER WIVENT _
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
,'Cv - • .
CITY. MECHANICAL PERMIT 'FEE '
ALTER OR,ADD TO MECH. -
APPLIANCE .
AIR HANDLING UNIT TO IUMC.F.M)' .
AIR HANDLING UNIT(OVER 100000 F.M.)
EXHAUST HOOD(WITH DUCT)
- HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT fOVER 100,0000.T.U.)
VENTILATION FAN(SINGLED -
BOILER-CONfl 13 N.P.or 100,000 B.T.U.) -
ROI LER-COMP Iu.�� Ioo 00o RTIll SEE FEE SCR.
TOTAL