22650 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add..: 2 2 650 50
10893 Aab/zr4 WOLFe' 2640 G G
am. APPLICA A
GAIL LaE 7,15-egge CITY OF CUPERTINO-BUILDING DIVISION r�� j
ClIon__eraaors / ^
Name: m.No: APPLICATION PERMIT I
� lea &LOW'.) 541�f3/ BUILDING-ELECTWCALML BING-MECHAMCAL CATEGORY CONTROL
- Architect/Engineer. Lit.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrese PERMITISSUANCE 1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affimnthet l am licensed under provisions of Chapter9(commenc API'I.1 J DFSCRB'I'ION
Ingwith Semon 7000)ol DlWalon3o(the Businemand Pro(nsionsCode,and my ,s.� •
I b In full fa and effect. / e/ PA 11
Limn lam Lic.X
Date 7 Cod nctor on UPM
ARCHITECT'S ECLARATION 301-1000
ne7 I understand my plans shall b,used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
GOG '"'� a�
U Licensed Professional SIG NSE A Lk L 1 U 2:1, C.�
�S. OWNER-BUILDER DECLARATION '1
Ci Fn SPECIAL CIItCU1T/MLSC
lhercm
by affirthatlam esemptfromlhe Contractor's License Law for the
f-W following reason.(Section 7011S,Business and ProfessionsCode:Any city or TEMP.M=OR POLE INST. E D I N
u1 county which rylresa permit tomtnmve
tct,alter,Impro ,dennlish,orrepair
. m
anystru=M prlortolts issuance,aLsorequirestheappllcent for such permit to POWER DEVICES
g a u file a signed Statement that he Is licensed pursuant to the provisions of the
Cu. Contraetorb License 1Law(Chapter9(mmnrncingwithSection7000)ofDivi-
n SWEHMINC POOL ELECTRIC
30 eion3o(theBwiness and Prolesslons Code)or that he exam therefrom and
VALUATION �
the bash for the alleged exemplbn. Any violation of Section 7031.5 by anyIL
OUTLETS-SWITCHES,ITX.TURESpy-
.y�� applicant fora permit subjectuthe applicant to a civil penalty of net comethan
q4' five hundred dollars($500).
NEW RESIDENTIAL ELECTR SQ.FF. SIOWES TYPECONSIRUCTION
/ ❑I,as owner of the property,or my employees with wages as their In
compensation,wllidothe work and thestrocture 9 not Intended or offered for
p .]a(Sec.7014 Business and Professions Code:The Contractors License Law
�S$ docs not a pply to an owner of property who Wilda or improves thereon,and OCC.GROUP RFS.UNITS
whodoessuchworkhimself orthroegh hisown employees,provided thatsuch
Improvements are not intended oroffered lorsale.If,howeveq thebuilding or TOTAL:
Impmwv ntbsoldwlthNoneyearofcompletion,theowner-WBderwlllhave
ft.tfurden of proving that he did cot Wild or Improve for purpose of ole.). QTY. PLUMBING PERMIT FEE
I_f L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the Emitter(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Contnetors License Law does not apply to an owner of property who ALTER-DRAIN kVENT WATER(EA)
Wroves ilda or Impthereon, and who contracts for such p -
(oects with a FEE SUMMARY
��tfactor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L-J I am exempt under Sec B k P C for this re
awn
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,CION I. SANITARY Y_ N_
RECEIPT 0
WORKMAN COMPENSATION DECLARATION FDalfRFS-M TRAP SCHOOL TAX Y_ N_
F11 hereby affirm that I have Insure,ora RECEIPT X
certificate o(Workam Compensation Insurance or a certified copy themof(Sec. GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
mini Lb C.) RECEIPT X
Polity Y GAS IA.SYSIFAI-0VER 6(FA)
Com any BUILDING DIVISION FEES
Certfied copyb hereby furnished. GREASE/INDUS[RL WASTE INTERCEPTOR PLANCI-IEC-
❑
Certified copy is filed with the city inspection division.
CERTIFICATE OF FXEM FTION FROM WORK BR S' GREASETRAP P rel
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F7, t CCCI t# L�"�+
(Fhlasenion neednot M completedB the permit la forone hundred dollars
(SI0()orlem.) WATER HEATER W/VENT/ELECTR EN CY N if
I mnifythat in the performance of the work for which this permit is heated,
1 shall not employ y person In any manner w as t subject to the WATER SYSTEM/TREATING PAID
Workcn Co�9a)p AlO Z Appli ant ff1�l aA f JJ NEW RESIDENTIAL PLMB. QEF. Date RC�ip
Z O NOTICETO IR II,after makng this Certl(late o(Exemptbn,you
Should become subject tothe Warken Comperetation provisions ofthe LaWr TOTAL: �y
N Code,yoa must forthwith complywllh Such provisions orthls permitshaghe BUIL FE —1
W > deemed nevokd. 41 C90
�y
CONSTRUCTION LENDING AGENCY SEISMIC FEE t�k.
CL Ihembyaflirmthat there is a construction lendingagenry forthe perform O TOTAL: ELECTRIC FEE 'Z
Zarice.fthe work forwhich this permit is lseacel&c.3097,CW.C.)
L) Lender's Name PLUMBING FEE
LL F- Legere Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify that l have readthb applicationand statethattheabove Information
u comat.l agree to comply with all city and county ordinances and state laws I'EItMITI55UANCE FEES PAID:
r 1 relating to building construction,and hereby authods representatives of this
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date RCC [#
(We)agree to save,indemnify and keep harmless the City of Cupertino 1 P
V agalmtliabllitles,7adgrrcnts,cosh and expenxs which may In anyway accrue AIR HANDLING UNIT(TO I0,0D0CFM) SUBTO AL:
agaimtmielciit(yf/q consequence ofthegr n ltMapermn. CONSTRUCTION TAX
W."/ XSGlI —/'t j9/ AIR HANDLING UNIT(OVER 1 owa CFM)
Signature of pplicant//Contractor ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplicant or future bu llding occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Rece
matedsI as defined by the Cupertino Municipal Code,Chapter 9.1 2 and the
Hess lth and Safely Code on 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL. 5tl
❑ yes ISSIN.
Will the a pplicant or lure re ion ilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hzzanlous air contaminants as defined by the Bay Arca Air a�er(1s
Quality Management Dlsirl (0 BOILER-COMP(31IP OR 100,0BTU) tiema4a�LJ
4 Yea
1 have read the M1aza materials requirements under Chapter 6.95 of BILLER-COMP(OVOL 100,00007L)
the Glifornla Health A Safety Code,Sect lore 2550.5,25533 and 25534. 1 (M1 hl"js�, �� �
understand that if the building does not currently have.tenant,that It 3 my NEW RESIDFNTIAL MECH. SQ.FT. ( yip '
responsibility,tonotify the occupant a the requirements which at be met
Prior t0b ce of a Certificate ojCttya my. ai
woe*
Owrcrlfrauthonccd agent Date TOTAL: ISSUEDBY:
OFFICE COPY