22539 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Pmo'ett Identification PE RMITNO.
Building Address:� E 22539
- sand
: A
weer. ams oneA A4: O/{/ L CITY OF CUPERTINO-BUILDING DIVISION
Con or's Name: Lk.Na:
APPLICATION I PERMIT
1� o BUILDING-ELECTRICALPLUMBINC MEGHAMCAL CATEGORY CONTROL X
Archactitect/Engineer. Lie No:
QTY PERMITFEE-
;�.d. ^s BUILDING PERMIT INFO .
,,� ,� ELECTRIC ' "
Addreu Q �+e ,9 ".1x= PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l see licensed under provisions of Chapter9(ce.i, APPLIANCESRESIDEN7IAL ]OB DESCRIPTION
mgwith SeLtion70t10)of Dlvialon3oflhe Buslnessand Pmle : e,and my ^� 1 s
liana le in full t and tl(ett. PANELS `I/J/ IIIIJ-
Lian Clan Lic.11 �/O d
Dat CantraRar �_r s �•/ I
ARCHITECT'S DECLARATION 201.1000 AMPS
ren ZO I undertand my plans shill be used n public remd. OVER I ODO AMPS SQ.FC.IL EA $ .FT.
1ZB Licensed Professional SIGNSELECTRI bio N
-<N. OWNEA•BNLDE0.DECLARATION SPECIAL CIRCUIT
°� Ih,.byaf(Irmlhatlame.emptfromlhe C.ntndor'e Li..IAwforthe
..ppoo following reason.(Section 7B.115,Business and Pmfeabns Code:Any city ar
coirtywhkh.,quimapenrdtromru ,talter,Impnm,de=lBh,ormpair TEMP'M67ER OR 7 ,
anysemmrephorwib) ancealsorequlmtheappllontfwmchpemdtto POWER DEVICES ♦�
o, file a signed statement that he is licensed pursuant to the provisions of the via
Contractor.LicenseLs.(Chapmr9(commenmgwhia Section 7000).(Diw.
heiseumptt neaf a mond SWIMMING POOL ELECTRIC VALUATION
tlon3ofthe Budnenand Pmdmlons Code).Nat
gj O the bora for the alleged exemption. Any violation of Section 70315 by any OUTLE7SSWITCHMFD=F.S
y applicant fora permit subjeata the applIcanttoa civil penalty of not more than
five hundred dollar Wall,
5 FlL as ownsr of the pmperty,.r my empl.ym with wage u theirsole NEW RESIDENTIALELECTR SQFT. SFORIES TYPE CONSTRUCTION
-c6 mmpenatlon,wBldothewmkandthesftm isnot eMedoroffemdfor
C q sale(Sec 7064,Buslnsn and Pro(enk)ns Code:The Contractors LIM.Taw
does not apply to son owner of property who builds or lmpeovn thereon,and OCC.GROUP RES.UNITS
who dansuch work himaeU.rthossagh hisown employees,Provided that such
bnprovements m rad Intended or offered for sale.IL however,the building or TOTAL:
Improvement 6sold within oro yearofcompledinkthe owner-builderwlll have a,
t enofprovingthat he did natbulld urimprove forpurpon ofuls.). Qjy; •;tic¢¢i,'"`:PtiUMB11VG PERM1'P, ,i ° =`t.FEE ': Hoon wNE ArN
L[u menet of the Property,am exclusively contracting with licensed p�I.I.LSUANCE Z
contractor to construct the project(Bee 70K Business and Prdessbns Code: ,00
The Commoara License Law does na apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds.r Imp.thereon,and who mMram for such pyom jewith a
egR¢acoaWBansedpumuntrothe ContnCm:Llanse lAw.
I am ne under Be- BACKFLOW PROTECT.DEVICE
mpt B&P C for this won
OUTSIDE FEES
DRAINS.FLOOR ROOF,ARENA.COND. SANITARY Y N
Owner Date RECEPT X
WORKMAN COMPENSATION DECLARATION FD(URFS PER TRAP '1 SCHOOL TAX Y_ N
hereby aRlrm that I have Certificate of connnt to sall-irame,(S . O.o` BBC=M
arti0ate of Workers'Compenntlon Inuunnce ma nrtRkd Lopythereo((Sec.
3800GAS EA.SYS EM.11NCA OUTLETS PARK FEE Y N
,
Pollsy XLb _jz RECEIPT X
Com any �[a��re aw ar GAS EA,SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
[jCenlO sup ls ere Tum ah7 e(.'��YTrrv.'/" � GREASEIINDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division. -
CERTIFICATE OF ET(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION WSURANCB SEWER-SANITARYSTORM EA 2WFT Date Recei t#
This section need not Mcompleted lithe permit I.for one hundred doll..
($100)arloes) WAT.Es(1tEA7,Es(ly/VpNT,/pyFF.crn ENERGY FEE Y N
I artily that in the performance of the week for which this permit is issued, —
1 shall not employ my person in any rranner n as to become abject to the
Date WATER SYSTEM/TREATING PAID
Workers Canpensstbn Love.t Gll(omis.
Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei t#
_ O NOTICE TO APPLICANT.If,after making thio Cntifirne of Excmptlon,you
should becamesubject to the Works.'Ga ruatioo pmWsimaofthe Labor TOTAL:
N Code,You mstfathwith comply with such pmvlsi.m.rlhls permit shall be
j dremed revoked. BUILDING FEE
GCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them Is a committing lendingagemuy torthe Perform
D Z ossa.(the work for which this permit ls Wued(5ea 3097,Civ.CJ TOTAL: D ELECTRIC FEE
O L^der'.Name �. PLUMBING FEE ,D
L F— Lender'.Addren QTY:: aC"MECHANICALF'ERMTT = ,FEET MECHANICAL FEE
WImrtlfythatlhsvcmadthlaapplicaOonaMGatethattheabovebformation
C ummmtt.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construciion,and hereby authorize representative of this
Z city to enter upon the above�mmntioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei [#
_ (line)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,cisesmd e.pensee which may In anyway active AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against al Aryl con quem (canting of this pertnlL AIR HANDLING UNIT(OVER 10,000 CES. CONSTRUCTION TAX
'�T
G
5: tu��Lunt/C ct� � Date ' IXHAD57 HOOD(W/DI1C7) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei [#
material as defined by the Cupertino Municipal Gone,Chapter 9.11,and the
Health and Safety Codem�-Sa-�ttim25531(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ,✓Q
❑YenL_I No
WBl the applicant or future building occupant use equipment mdevkes VENTILATION FAN(SINGLE REBID) IS$�sL�]4ZaDA'f'E
which emit hazardous air contaminaa nts defined by the Bay Area Air rJ
J
,. Quality Management District? - BOILER-COMP OHP OR 100,000 BTU)
Yn r,No
`I gave read the hams ma materials requlreme^tsunderChaptere.95 of BOILER-COMP(OVER 100,000 BTU) u� 5 1 �
the CaWamis Health&SafetyCode,Sedlon25505,25533 and 25536.'] _ .
understand that lithe building don bot on.ently have a tenant,that It is my NEWRESIDENMALMECH. SQFT
6'
responsibility to notify the occupant of the requirements which most be mart �1J6n,s�/Iesesaa►assaa
prim to issuance d a CArtiOcate ofOccupamuy. MV atcu lVllFe
OwnerceauthorluM agent
s - Date TDTAL ISSUED BY; .
OFFICE COPY