22296 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
PERMITNO.
Building Addrcu;
1122296
s-
w-S'//,S 7
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION/PERMIT
BUILDING-ELECTRICALPL-UMBING-MECHANICAL
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CATTGORY
CONTROL M
Arch it I En gj Moz�l Lic, No:
QTY ELECTRICPERMIT FEE
—
BUILDING PERMIT INFO
Add.
11 DU hL�l PLUMB MUCH
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
-herebyion70thatl amlken3 oftheertrugialooso(Chapter9(m.od my
Ihgwilh Sectl°n7000)ot Division 39(the BuNnessandPro(eulonsCode,and my
Llreese Laos
Licesso le in full 'fo d ceo-
Lk. N
APPLIANCES•HFSIDENffAL
JOB DFSCRR'ITON
s,,, ' `�' 1�
/�-FL.-1'�.`
PANELS
V
Date Cor,- r 'UP
TO 2DQAMI!S
Fa
201-1000 AMP"'
ARC. 'IT DECLARATION
Iunderstandmyplaos ehallbeused as public records.
OVER IOW AMIsS CUE
DSQ. rKR AREA $/SQ. FT.
Licensed Professional
OWNEReBUILDER DECLARATION
I herewing r atNm that .. 70314,
031 sept form the Contrsctofelimnse Law for the
(aunty whieasequicecti°n7 itS,Businesaa nd PImprove, Code: Any city.,
countyTpdp
muntywhlch requlr to mosbuct,alter,Improve,demolbh,errepao
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC
XTER
/
METEROR POLE [NST.
itspermit
itsshat he is abo equireathe pursuant t the pr such ublons of t e
any awdvre priortostatement
file a signed statement that he b r9(commencing
colicensed pursuant to the pro 7000) f the
Contractor's License d(ChaptemCode)enclngwlth Section
mptthem)ot Divl-
amn3of the Busineuand Profeml°ia Code)orthat hebexempt there(romand
the bash for the alleged exemption. Any violation °f Settlor 70315 by any
applicant fora permit subject°the applicant to a civil penalty of not more than
five hundredI, as
❑I, es owner thepro
the property, or my employees with wages thele sale
POWER DEVICES
/
SWpLYgNG POOL ELECTRIC
OUTLETSSWITCHESFIXTURES
AALUATION
Z�
NEW RESIDENTIALELECIR �'�'
-STORIES
TYPECONSTRUCTION'
ll
wlldothework.andsh.CdurebnotmtendvdoroReredfor
r
ole (Sc.7W4.
sals(Scompe.7W4. ahem and Profeasku Law
to who builds or Impom," hems and
doss netapply to an owner ofpropertyhisonem orimproovidedmryuch
hisownemployees,providedthatsuch
whoovementsa
OCC.—GROUP
RES UNITS
nhimselfedorough
improvementsarenot Intendedearofcdforsab.tLhowever,ilder ill have
Imprrvemrnt boold withinoneyearofcompleliOn,the owner-bullderwill have
ttte burden of proving that he did not build or Improve for purpose of sale.).
M 1, ae owner of the property, am exclusively contracting with licensedF100D
contractors to mutrud the project (See 7074, Business and Profeml°re Code:
TOTAL:
'
QTY. PLUMBING PERMIT FEE
PERMIT 1T ISSUANCE
ZONE
MIN
The Contractor's License Lw does not apply to an owner of property who
builds or Impry roves thereoand who contracts fee such p(ojecv with a
TT((+ctor(s) Brensed pursuant to the Contracts. Licensee Law.
IC". am exempt under Sec. B & P C far this reason
ALTER -DRAM &VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
-
DRAINSFLOOR.ROOF,AREA,COND.
SANITARY Y— N
RECEIPT if
Owner Date
WORKMAN COMPENSATION DECLARATION
❑i hereby affirm that t have mrturanc of consent to tnwre, or
FD(TURF_& PER TRAP
SCIdOOL TAX Y N
o copy
3800certiLaeof Workers Compensation Insurance orarertlfkd copythereof(Sec.
3500, GbC_7
� - ��
RECEIPT 0
GAS- EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT p
GAS-�
GAS PA. SYSTEM -OVER 4 (G)
Co_'5� �_ished.
BUILDING DIVISION FEES
ertified copy atwreby th the city
Certified copy b filed with the city Inspection division.
GREASE/ INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(0section need not be compiaed Rtbe pnpermitb(or ane hundred doldollars(or tem')
$tm)m
I certify that In the performance of the work for which this permit l° bored,
I sha0 not employ any person in any manner n as to become wh t to the
Workers' Compensation Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Examyou
should become subject to the Workers' Competent ion provisions Of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
dermad revoked.
PAID
Date Recal tN
SEWER -SANITARY -STORM FA. 2tX)FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Daft Recei t#
WA.IPIi SYSIAf/,I,REA.IING
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
G FEE
CONSTRUCTION LENDING AGENCY
lherebyafBrmthaltherebamutruction lending agency for the perform-
ante of the work far which the, permit b Issued (Sec. 3097, Civ. C.)
Lender's Name
Lendee.Addreas
I certify lhatl have read thbappBcationand Rate thattheabove Information
SEISMIC FEE
TOTAL:
FEE
Q'IY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEE —PAID:
bcorred.149motocomplywithaudtyand muntyordlnancesand state lawn
PERMIT ISSUANCE
relating to building comlrutt(on, and hereby authodve reposentallvesof thio
city to enter upon the a bove-mentioned property foriropectbn purposes.
(We) agree to cove, Indemnify an d keep harmless the Clty of Cupertino
ALTER OR ADDTO MECH.
Date Recei tN
against liabilities,judgments, rostsand expenses which may In anywayaccruo
a imt uld City In consequence of the granting of this permit.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000C[M)
CONSTRUCTION TAX
Sigoatvre of Applicant/Contractor Date
EXHAUSIIIOOD(W/DUCO
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UNIT(TO 100,0000TJ)
--
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Date Recei tp
P
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Heahh and Safety C°dexkctlon 8532(.)1
NO
1-1 Yes No
VENTILATION FAN(SINGLE RMD)
ISSUANCE DATE
I :
TIYi$1
Will the applicant o building occupant useequlpment°r devise
which cent havrdcus air mntamloants a° defined by the Bay Area Air
Quality Management Dlst d7
Yos No
ROMER-COMPOIR'OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)Juil
4 have read lhehaz us materials requirements underChapter6.95 of
I' f,
the California Health&Safety Code, Sections 25505,25533 and 25534.1
N Y `9
���
NEW RESIDENTIAL MECH. SQ.1•T.
understand that if the building does not currently have a tenant, that It is my
responsibility to notify the occupant of the requinemeniawhich must be rrrl
prior to Issuance oda Certlf i fff occu ancy.
as $/s.W.!!O�
My set W+�Inn
ISSUED BY:y f/YJ- w t jut L
Ownero ih rri-
TOTAL:
OFFICE COPY