22137 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Peeled Identification (/�f _ ` )(, PIRLMITNO.
Building Add ..:� ..� •. 2 213 7
ners ante: V one: APPLICATION SUHMni AL DMEC
CITY OF CUPERTINO-BUILDING DIVISION
Contratt°r',Namm: Lic.N.: APPLICATION I PERMIT !
Architect/Engineer. Lie No: BUILDING-ELECTRICAI.PLUMBING-MECHAMCAL CATFfARY CONTRQt 1 1 06
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ('r�,170 [! � ` ❑
LICENSED CONTRAROr pr DECLARATION �/] JOB
I hereby ectionrmthat laIvsion3 ofthe underproviders
rof Chaofess ler9de,and c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
InensetSection to.and effect.
ofthe Buslnnsand Pro(eseloneCade,and my ^ —
LI.. Ie In full(ors and offset. PANELS C.F..�•`(_
License Clam Gctl I 2 .--�1 (�
Date Gantradar .S // K� a
ARCHITECT'SHanesused
a public
OVER
AMPS
quq�aa ceO Zp Iundentand my plant shall be used ee publlerecmds. OVER 1000 AMPS SQ.EFF.FLOOR AREA / 5/SQ.FT.
Licensed Professional SIGNSELECTRICAL L4 T 1 L ��
6 tLry7 IOWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC a.� 7,t ry
79 owing ra(firmthatlam31.5,B from the Contractors Littnse Law for the �"7'� /F7 f lt-1.
C lounwingrcamn.(Section
perm11S,Buainen and Professions Code:Anydtyor l 1-f�
O TIMP.METFR OR POLE INSI. �a�.
K� eny.tm=mpntywhich r ritoiaisma eaLwract,alttheappHuntfrtnWhper, ttopair rT ^ rys-T
a any,tmcturetteerm lfslsaa eb lici regpursuaattothe rovidlccof to POWERDEVICES
U file..igned License
that he V lircnsed pursuant it the tom 70ow a( the
a,FF, Contractor's Llceme Law(Chapter9(mmmencingeile Mmptthom)o(DWI- SWIMMING POOL ELECTRIC
BOJ the basis fo the alleged exemption. Any)violation
of section 031.5 by any VALUATION
the basis for the dieted exemption. Any vlolacon of Saloon ract m by any 36 0UTLETSSWITCHES-FIXTURES , ,p 117,
7 r
appBttntfor a permit subjects theapp0cant too civil perultyofnot morcthan `�
$ firJundrcd dallan STORIES(5500). NEW RESIDENTIAL ELECTR_SQ.FT, STORIES TYPE CONSTRUCTION
�n Lj 7,as owrmr of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not Intended or offered for
O sale(Sec 7040,Business and Pretensions Code:The Conkanoes Lisme Law
$ does not apply to an owner of property who Wilds or improves thereon,and EE __ OCC.GAOUI' RES.UNITS
who does such work himself Ns own employee,,provided that much
improvement are not Intended oroffered for mate.If,howeveq the bulldingor TOTAL:
improvementtsold withinomyearo(completlan,Iheawner-bu0derwlll have
tllpjZurden of proving that he did not build or improve for purpose of QTy, PLUMBING MI FEE FTpOD TONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMI.I.ISSUANCE e D
contractors to ronstruct the project(Sec 7044,Bushow and Profe Blom Code: Q
The Contredora License Law does not apply to an owner of pmNrty who ALTER-DRAIN VENT-WATER
Wild,or Improves therein, and who contracts for such pWIects with a
c<RBTator(O ficensed pursuant to the Contractor's License Law. BACY FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this mason
Owner ate
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
DRECErpT#
WORKMAN COMPENSATION DECUBATION FX111RES PER TRAP p OOL TAX Y N
❑I hereby affirm that I have'a certificate of consent to self-inare,or a RFCE1PT tl
cediflrat<ofWorken'CompewUon Wurenttora certified mpythereaf(Sec.
3800,Lab C.) GA&EA.SYSTEM•I P1C.4OUTLL TS PARK FM Y_ N_
policyR5ef1PTCo. GAS EA.SYSTEM-OVER B CDIVISION FEES
❑Crtified
copy is hereby thecity famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy t(fled withhthe inspection division,
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE /A�
(This aedlon needcad be completed if the permit t foram hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Revel tet O 4
($100)otifythat I.the perimmance of the work(mr.hich this permit 1.issued,T WATER IIEATER W/VENT/ELECTR ,�r�YY ENERGY FEE Y N
l,hall not employ an/person In any runner so es to become abed to the
Wor / WATER SYSTEM/TREATING ,(� PAID '
licrs'Compensatlon Lowe of California. Date a
O Z Applicant NEW RESIDENTIAL PLMB._SQFr. Date Rech tet
Z Q NOTICE co APPLICt to the
ager moldrWorkers'
pe Certificate pre ofExemption,oft the
H Code,shoulyou must
hwitthe Work en'such pwtlons orthiomrmit s Lab be TOTAL:
Uj N Code, muzi(orlhwlth comply with such provblom or this permit shall be
> deemed revoked. BUILDING Q
ac CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyafflrmthattherelse comtadlon lending agency for the perform- TOTAL..
ELECTRIC FEE 3O
Z coat of/he work(or which lhtperndt t Issued(Sec.3097,CIv.C.)
0 O I,mdcrmName PLUMBING FEE f1
LL F Lender'.Addnss QTY. MECHANICAL PERMIT E MECHANICAL FEE
O W Icerti(ythat I havereadthisappllatlonand statethattheabove Information
t rorreatlagreelo romtmetkhaedtyandmuntybee repnces move.(.taws ISSUANCE FE S�. P�I f
y relating to building rovtadloq and hereby mthorlae rcpresentativn a' him _�_('�/T
Z citytoenterupon the mbmv nrenitomd property for inspection purposes. ALTER ADDTOMECH. DatC-4•� 6R22
IN
— (We)agree to save,indemnify and keep harmless the City at Cupertino
against liabilities,jydgmeots,mrtsandexpense.which may In anyway attrue AIRFUNNCUNIT(TOI0,0W CFM) SUBTOTAL•
ag a Il in rocas acne of the granting of this permit '
610_4?r AIR HANDW GUNIT(OVER10,060CIM CONSTRUCTION,TAX
Signature of AppB=O'
a /Contract Date IXFiAUS'I FICO /Di1CT)
CONSTRUCTION TAX PAID:
HATARDO MATERIALS DISCLOSURE
WIII Me applicant or foto bullding occvpant,mreor handle hazardou, F(F.AUNG UNIT pO ,000 BTU)
materbl as dellmd by the Cupertino Municipal Coda COhr.;r9.12 and
the Date . Reeei tN
Ilealth and Safety Code Section 25532(a)? HEATING UNIT(OVERI 000 BTU) TOTAL:
❑Yes M No
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE D) ISSUANCE DATE
which cent hazardous air contaenmnt as defined by the Bay Arca Alr
Quality Management District? BOILER-COMPOFRPOR 100,0008
4hYes ousNo
avcread the h,za materlals requirements underChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California health k Sa(ety Code,Sections 25505,25533 and 25534.I t1111( d 2 �
understand that if the building does not currently have atenanq that It t my NEWRFSIDENTIALMECH. JTOTAL,
JE�IF
responsibility to notify the occupant of the requirements which must be encs
prior to Issuance of a Certificate Of Ottupancy.
Owner or authorized agent Data ISSUED BY:
OFFICE COPY