22906 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pra ea Identification PERMIT NO.
Building Add Fees:
23,00 ��k 6m 5,j;>&.e 22906
nero ante: one:
N/rC P {N,2s in/ S 9 / X37 CITY OF CUPERTINO-BUILDING DIVISION
Conl.d.e.N.me: LTc.N.: APPLICATION /PERMIT
d;,'0673 BUILDING-E.ECTRICALPLUMBING.MECHANICAL CATEGORY CONTROLS
ArchlteR/Englnter. Lic.No:
QTY ELECTRIC PERMIT peE BUILDING PERMIT INFO
Address PERMITISSIIANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter 9(commenc. APPLIANCE4.RESIDENITAL IOU DESC
Ingwilh SecBon7000)of Dlvtalon3ofthe Buslnessand ProfesslonsCode,and my
B¢nse I.in fun fo and died PANELS Ynrf/�
Lt¢n.e Clam Ltc.a �Fyubd
Cana ARCHITE 7111-1000 AMPS�qqF!!�ZO Iuedem/and my Ebro ehaBbeOVER tO30AMPS, 1 �SQ.Ff.FLOOR AREA S/SQ.FT.
E IJ E Licensed Professional SIGNS ELECTRICAL IA
LED OWNERex NLDER DECLARATION ¢ r� tP� I
In a SPECIAL CIRCUIT/MISC LI IV/
(.., owing ason. Shalom 31.5,B from Contractor's License Law lmthe
X following reawn.(Section 7m1.5,Business and Professions Code:Any city or
O
cauntywhich requires apermit toroutruR,alter, m
improve,demolish,orrcpalr 'TEMP.ME[EROR POLE INST. I
any.tructurepriorloltsissuance,a]aomquimslheappllcantforeochperMtto POWER DEVICES
F
file a signed statement that he V licensed pursuant to the provisions of the
u. Contactorb License Law(Chapter9(commencingwith Section 7000)o!Dlvl. SWIMMING POOL ELECTRIC VALUATION
t„�O,p eion3olthe BueNmand Prv(ceebruCode)orthat hebexempt there(romend '
9 the basis for the alleged exemption. Any violation of Seddon 70115 by any OU'ILETSSWITCHFSEXTURES
applicant fora permitsubjects the applicant to a civil penalty of not more than
fivs hundred dollars($50f. NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees In with wages as (fele d fo
compensation,wuldo the work and toes Code:The
Is not intended or License L for
q '
sale(Sec.apply
to an ow and Profembm who builds
or improves
License law
:-' don not applytork owner o!property whonIlesorImprovededthryand
d3ti
who does auchworkhimself orthrough hisownemployees,providedthatsuch OCC.GROUIP RES.UNITS
Improvements are not Intended orotfered!oraw
le.If,however,thebuilding or TOTAL:
Improvement h sold withln oneyearofeample0on,the owner-builderwill have
t rdenohprovinglh.t he did notWfldorzFpmvxfmpurpoxof.I.,L QTY. PLUMBING PERMIT FEE FLOODZONE APN
Lj 1,as owner of the property,am exclusively contracting with Iirensed PERMIT ISSUANCE
contractors to rost
nmet the project(Sea 7014 Business and Professions Code:
The Commences License law don not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or improves thereon,and who contracts fm such ptojem with a
.go.etes(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. 0 A P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date - RECEErf p
WORgNAN COMPENSATION DECLARATION FIXTURES.PER TRAP 5CHOOLTAX Y N
❑I hereby affirm that I have•rertifiate of concent to opytneure,ora RECEIPT It
3800,Lab ofWorkers'Compewtlonlruuranaorattrtlfled ropythensrl6ec. GAS E.A.SYSTIM-1 INCA OUTLETS PARK FEE Y N
3Blic Lab C.)
Policy M RECEOf M
CmaGAS EA.SYSTE/-OVER 4(EA)
BUILDING DIVISION FEES
Certified copy b hereby filed
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b hike with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thbsedlan need nal bm
e copleted If the pertNt V for one hundred dollars
a100)mleas.> WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
lent thatInthe perso.In oft he work.as
bco pemdtiswaed, —
1 shall not employ any pL. In any manneria as to become ar to the WATER SYSTEM/TREAIING PAID
Worlicant m sailors laws o(GII(omy Date—T_1—s/
O Z Applicant �bT16Lyls making
this. a
Z O NOTICE TO PLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PCMB. 5QF7, Date RL'cel [#
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Cole,you=at fort hwith comply with such provisions or this permit shall be NG,
deemed revoked, FEE
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herchy affirm that there lan construction lendleg agency(or the pedorm, ELECT-RIC FEE
Z anceofthework forwhichthb permit is Issued Ogre.3D97,Clv.C.) TOTAL:
U O lander.Name PLUMBING FEE
LL 1- Lender'.Address QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
U I artilythat I have mad thbapplicationand statethat theaWo .e famadon
O W Vrorrect.Iagree to comply with alldtyand county ordlnanmand elatelaws PERMIT ISSUANCE l r� FEES PAID:
} IL relating to building construction,and hereby authorize representatives ofthls
F N city to enter upon the above-manti ned property for impaction purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harMc the City of Cupertino - Date ReZ
V against liabl ,judgments,cressand expennw h Trey hi.eyway.ccrus AIR HANDLING UNIT(TO 10,000 CFM) SUBT
against ea C In roe core alt granlln his perm .
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Signature o p ant/Contnctar Data EXHAUST HOOD(W/DI1CD CONSTRUCTION TA
HA7A R DOUS MATERIA SCLOS URE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Recei t#
reaterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the _
I Iealth and Safety Code Section 25537(a)? HEATING UNIT(OVER 100,000 BTN
Yes Na TOTAL:
illlhe xpplicer r/utue,building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
q
which emit hazardous air rontamivnb as defined by the Bay Area AU
Quality Management District? BOILER-COMPOHQPORID0,0001HN P P9 A ' D
4Vas o
h.vereadth.h ousmateriabrequimm nmunder Chapter6.95of MOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 25505,25533 and 25534.1 OCT 25 �gg�
understand that if the building does not currently have a tenant,that it b my NEWRESIDENIIALMECH. SQ.FT.
rnor to_ tonoll Car, occupant (the rcqulremenb which must berth
priorlo n¢of Certl/late o! ccupanry CITY UO(F�CUPEMIIrvu
Owner o0illorrized agent Dante
TOTAL _. ISSUED BY:
OFFICE COPY