22334 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Idratiftcmion PERMITNO.
Building Address:
22334
wrier. ams: one:
st 14 CITY OF CUPERTINO-BUILDING DIVISION
c°""'"°�•"•r^•° Lk.N- : APPLICATION / PERMIT V
Arc ked/Engineer: Lk.N 7 BUILDING-ELECTRICAI.PLUMBING.MECHANICAL CATEGORY CONTROL#
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE L MH IT
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I bare/y,affirm that l am licensed under provisions of Chapter 9 fixonarnme, APPLIANCESRESIDENML JOB DESCRB'DON
ingwlth Sedion 7DEBO(DIWsIon3ofthe Busineuand PmfessionsCode,and my
license le ln� ddf�oF. 2 7 PANELS / �� I�e� -
Limn Lk. ,3�j� /J/bj s}. W (��(
DaIe�TContrador' Y
ARCHITECTS DECLARATION 241-1000 AMI'S
q�+N Zp Iundentand myplaushxRbauvedaspubileroccedt. >` OVERIODUAMPS _ 5/SQ.FT.
M,
Licensed Pfamim
roal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
I-n`Cd SPECIAL CIRCUIT/MISC "' : �]�)Q '
owing axon.(that lamexempt firear,013,Sugar.a G-ntraa i.Limnte Law for t he �-
(olbwing reason.6edlon 7Q715,Buelnesa and Profenlone Cods:Any city or
02—pp TEMP.ME1TR ORIOLE INST. e_
Pm of cnystru mpdorlesoperants-utmd,altheaprovgdemoBah,erepair .f
W6$$�[ 7 anystm ed pdortoibhatha ,almesedhestuanthothe pro ialomof t e POWER DEVICES 1,
K�1 6 file a signed gatement that be is Bceneed pursuant to the provlslou°( the
6Q3µ,1l-� Contradorb LiceueLaw(Chapter 9(commencing with Section 7000)°(Dlvl- SWIMMING POOL ELECTRIC
VALUATION
the
sion3ofthe Businuaand Profeul-mCode)orthal hekexemptthcrefromand
Q.•77 the basis for the alkged exemption. Any vl°Iation o(Section 7071.5 by any OUTLETSSWITCFffSFIJGV12F5
applicant fora permit subjects theappllcant to a elvil penalty of not momthan
w five a,o demodollarthepr. NEW RESIDENTIAL ELECIR SQ.FT. --§T FEES TYPECONSTRUCTION
�n
[:]I,e a owner of the property,or my employees with wages as thele sole
mmpen.7044,wuai ...ldothe work and the Code:
Is not Intended oroffered for
O sale(Sec.7044,Business and Professions Code:The Contradote License law
S$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
e• who dousuch work himself or through his own employeµ,provided that such
Improvements arc not Intended orof(ered forazle.If,howevep lhebuilding-r TOTAL:
improvement Issoid within one yearof completion,/he°caner-bullderwill have
0B,jIurdenof proving that he did not build or improve for purpose of vale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the pmpmty,am exclusively contracting with Ileensed PERMIT ISSUANCE
mntract°n to cong4uct the project(Sec.7044•Business and Prof egic rs Code: 12-00
The Conradoes License Law does not apply to an owner of property who ALTERDRAIN 4 VENT-WATPR(EA)
builds or improve thereon,and who contracts for such pkejeds with a - FEE SUMMARY
masoncgp(factorW Licensed pursuanttotha Contndo/v Llcense Law. BACK FLOW PROTECT.DEVICE
L-�I am exempt under Sec. B k P C for this mason
DRAINSFLOOP ROOF,AREA,COND. SANITARY V N_
• Owner BBC=
WORKMAN COMPENSATION DECLARATION ARATION FEKTURES PER TRAP SCHOOL TAX Y N
a Ili hereby affirm that I have o Insurance
of concent to opythwre,ora RECEIPT N
Ifiute of WorkersCompeuatl-nluurancemacerti(led copy thereof(Sec.3800,Lab GAS EA.SYSTEst-1INCA OUTLETS PARK FEE Y N
PoOcyN 1.t;,Gc/7Do ? 2—/ RECGAS EA.SYSTEM-OVER 4IPAI DING DI VI
Com any BUILDING DI VISION FEES
pemfied copy I,herebyfurnished.the city CREASE/INDUSIT,WASTE INTERCEPTOR PLANCHECK FEE
�.7 CedlBed copy k(14d with/he city Inspection divislOn.
•`�" CERTIFICATE OF EKEM FFION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.Zf10FT. Date RCCei t#
(Thissedlon need not be completed lithe permit isfurors hundred dollars
($100)Offe'ss') work WATER HEATER W/VENT/ELECTR _OV ENERGYFEE Y N
I certify that persa In
so as to permit Is issued,
I shake not employ any person in any manner so u to become mbIed to the WATER SYSTEM/TREATING
Workers'Compensation Tawe of Calif-rnla.Date PAID
Q Z NOTICE
Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICEcomesu jc"tot If,afterthe
makinWorkers'Compensation
nCertnlcateofoxempt the
should become turfed to lee WorkershsuchEovist s orthiou of the Labor TOTAL:
�LU W Code,youremuet forthwith comply with euchprovbbuorthb permit shall be BUILDING E
j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby af0rm that them is a coutrudlm lending agency forth perform- ELECTRIC FEE
Z anm°flheworkforwhechlhis rmltislesued(Sec.M97,CIv.C.) TOTAL:
U O Lender's Name I PLUMBING FEE
LL I— Lender's Addram QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mnifythat l haveread thisapplicattonand gatethattheabove information
1 iscorrect.l ugreeto compiywith all cityand county Ordinances and state laws PFRMTTISSUANCE FEES PAID:
>. W relating to building coutrudlon,and hereby authorbe representatives of this
HZ dty to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECLDatC
— (We)agree to save,indemNly an d keep barrel.the City O(Cupertino Receipt#
against liabilities,judgments,mans and expenses which may In any way smaue AIR HANDLING UNIT(F010,000 CFM) SUBTOTAL,
agalul said City in uenca thrgrantingofthisportnit. sLr)
AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
tum- Applicant on radon Date EXHAUST}{Opp(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappLicanl or future building onvpanbtore-r handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Codr Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: UI/
Yea ri No
Will the applicant°rfuture building occupant use equipment or devise VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as de0ned by the Bay Area Air ���
Quality Management District? BOILER-COMP DHPOR 100,000 BTU)
4Yee ❑❑No
have read the har ousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,f1(p BTU) ��r Q y^^�
the California Health h Safety Code,Sections 25505,25533 and 25534.1 4 V s9
understand that lithe building does nm currently have a tenant,that It Ismy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to amily the ocevpant o/the mqulcements which at be mat
prior to Issuance of a Certificate Of Occupancy. at of
/1..__j._
�G.I}/!.I'1FC,W�{R/hjs�,lFa t
Owner or authorized agent Data
ISSUED BY:4
TOTAL: tea' ((( 1/U✓ I
OFFICE COPY