22596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
•� .a Build] Yro'ect
Identification �� It J 1193 TNN
Building Adders:
_ � �W%TA 22596
r.-.-.17 a hone:
/�p(sg PjCL-` CITY OFCUPERTINO-BUILDING DIVISION I 1
CaTa�eata%a N•n,e:^�- ,� a�./�_+ Lie.No: APPLICATION / PERMIT
�SZ6� BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL at
Arehitect/Enginar. Lic No:
6 ` QTY ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
Add.. PERMTISSUANCE
LICENDC � O
DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APr'LIANCIr RESTDENIIAL JOB DFSCOFflON -
ingwith-gMio 7000)0!Division3afthe Bustnmsand PmfessionsCode,andmy
liansebinfull andeffect. .. / C('2— P � r
Lirense Ca LIe.M z i
Date Contractor IM A
ARCHITECTS CLARATION 201.1 MPEI r-7
arh
0 Z I understand my plana shall be used as public records. OV 5Q.�rF'r.`FLOOR AREA II$y//SQ.FST.
Z00 Licensed Professional SIGNS ECTRICAL I J 1�']1t yy1
<«<�6 y OWNER-BUILDER DECLARATION 'SPECIZL Chwq
L, 7 (hereby affirm that am exempt from the Contractors Llrene law for the
7.p following reason.(Section 7031.5,Burinessaad Professions Code:Any city or L41��
TQaP.METER OR I'OI.E I
bountywhich rcquirera permit toconswct;alteq Improve, erro
dlbh,orrepair
q��Cci aoyswcture pdorto its Issuance,also requirestheappliant forsuch permit to POWER DEVICES '
E V file a signed statement that he is licensed pursuant to the provislam of the
µif Contractors License Law(Chapter 9(commencing with Se cion 700())of Divl- SWIMMING POOL ELECTRIC
EI sion3ofthe Busleessand Professions Code)orthat he is exemptthamfromand VALUATION
O O the basis for the alleged exemption. Any violation of Sectio70HS by any OUTLETS—SWITCHESSFIXTUR 32 -q.364 �2
appBant for a permit subjects the applicant toa civil penalty of not more than
F (ivC hundred dollars($500).
mf NEW RESIDENTIAL ELECTR SQ.FT. RTES TYPE CONSTRUCTION
.- M I,as owner of the property,or my employees with wages as their sole
7 a rompereatlon,will clothe work.and the structure isnot intended or offered for
0 sale(Sec 7044,Buslnens and Professions Code:The Contractors Lirense Law I 4
F�$ does not apply to an ownerolpropertywho buildsor improves thereon,and OCC.GROf1P RFS.UNITS
whodoessuchwork Meselforthmugh hisownemployees,provided thatsuch t�
improvements are not Intended oroffered forsals.It howaveq thebuilding or TOTAL:
improvementbsoldwllhinoney arofcompletiontheowner-builderwW)uve
the rden of proving that he did not build or improve forpurpeseofals.). QTY. PLUMBING PERMIT FEE
I,as owner of the property, FLOOD ZONE APN
p petty,am exclusively Business
and
with licensed PERMIT ISSUANCE
TheocrCo ar to construct the project(Sec.70W,apply
Business aner of property
Code:
The Contractor's improves
es then Taw does not apply m an owner of property who ALTER-DRAIN k VENT-WATER(EA)
colids or Improves<pursua and who contacts for such plvjem with a FEE SUMMARY-
roet{actor(aexempt under Secnt.
the Contractorb License Law. BACK FLOW PROTECT.DEVICE
1_,J I am exempt under Sec. B &P C for this reason
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT a
WOR KMAN COMPE14SATIONDECLARATIONFIXTURES PER TRAP SCHOOL TAX Y N
F-11reffi
T hereby arm re
that I have a certificate of consent to self-insure,ora RpCplpp N
certificate o(Workere Compensaaonlnsurana oracertilled copy thereof(Sec. GAS EA.SYSTEM-1 INCAOU1LETS PARK FEE V N
3800,fab RECEIPT
11-11c,
p / 7 C GAS F.A.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FOES
Certified copy is hereby furnished. GRFASF./INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
K(Cenlfied copy la filed with the city inspection division.
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Dille CCC l# t�
(ITlssetlion need not be completed If the permit is foroce hundred dollars
($100)otifyth WATER HEATER W/VENT/ELECTR ENERGY FEE
I cent that In any personhe Ian tmannerhe work so as to become
eenNt is issued, V�O
I shall not employ any Laws in any manner eo ar to become subject w theWATER SYSTEM/TREATING Workca Compenatlon laws a(CaB(arnia. Date PAIDnt
Z ZNOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you NEW REST DENTTAL PWB. SQFr. l I#
should became subject to the Workea''Competwtlon provisions of the Labor aL:
CCN Cod,you must fort hwlth comply with such provislons or this permit shall be Lf k1+0 BUILDING I
LU > locoed revoked.
a lherebyalRrcONSTRU(.TION LENDING AGENCY SEISMIC FEE �317L
mtMt there is a construction lending agency for the perform TOTAL: ('+) .y(� ELECTRIC FEE C)
Z once ofthe workf wh Ihb rmit Lvov .309'{Cava l
(� O lender's Name✓ o PLUMBING FEE qfl
H Lender's AddressQTY. MECHANICAL PERMIT. FE& 40O W' Icertlfythat7 a th appBationand statethatthe above information MECHANICAL FEE
LU correct.Iagree to comply with all city and county ordinances and state laws PERMITISSUANCE 12sCD FEES PAID: -
} N elating to building Instruction,and hereby autharlu representatives of this -
_ city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
2 (We)agree to ave,Ind smelly an d keep harmless the City of Cu penin Date R eipt#
V
against ltabilit ies,pdgments,costs and expenses which may in any way acerae AIR HANDLING UNIT CFO 10,(00 CFM) SUBT TAL:
against s In conaequ a of the granting of this permit a/ cc a
tAIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TA
Sign of pyicant/Contactor Dae T� EXHAUsr HODD(W/DUCD CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE I -
Willthca ppllcant or future building occupant store or hand le haiardous HEATING UNIT(TO 100,000 BTU) Date Rece t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —-
1lalthandSafetyConon 25532(a)4 HEATING UNIT(OVER 100,000 BTI) TOT �00
❑ Yes ���+C�t0
Wlllthe appllantbrfuturc bclldingeocupant use equipment or devices VENDLATIONFAN(SINGLERESID) ISSUANCE DATE
which emit havrdous air contaminants as dented by the Bay Area Air
Quality Management s ct7 BOILER-COMP(3Fm OR 100,0(0 BTU) p
4Yes P.4 p
have read the h a as ous materials recto imments under Chapter 6.95 of BOILER.COMP(OVER 100,"BTU) .3ryry^II (/
the California Health k Safety Code,Sections 75505,25533 and 25534.1 •ro
understand that if the building does not currently have a tenant,that it lr my NEWRESIDENHALMECH. SQ.FT. I/ q
cu
responsibility to notify the aepa at of the requirements which mist It
priortofa Cenl tc ofOmrpancy. •'l`� Vl/Yu 1991
Owner or authodeed agent Dater UEDg ti
TOTAL: ISS
OFFICE COPY
ADDITIONAIII PE'RMITP FEES' '
BUDLDLNCPRMECT1I DENTEFICATiDMVALUATIONN
ooaEsss '
o Ea's
FEEISUMMARYY
cawranc ss - BUILDING:—,�.� '✓�•" '
� AYLVd
FEAN`CHECKK -.�
owTa ncToass FEEEi .
POOPEs45 ` � q'c�
". .•n:(72-36 S'Ct.-t�E.' �oAo / / G 7J 7LZ SEISMIC'FEEf. - 41
UTVt .'EEECTRICPERMITT I FEEE x
�., UTLETSS SWITCHESS RECEPP 1ELECTRIC �•
LIGHTING;FIXTURESS' .�PCUMBING ':
.. {. APPLIANCES`RESIDENTIAL)
PANELS MECHANICAIL {
{ SIGNSS
- w i SIGNSTRANS` y 1 --F TOrA�.L f
SPECIAjc,CIRCUITT 1
PERMIT VALIDATION V
y_ J ,EMP METER-:OR POLEBNSS
MOTORSS .SEE FEE SCH.-
SERVICE(CHANGEE �- {
F . { TOTAL' % V /.
_'N • ISSUANCE OATFF
Lu > OTY. PLUMBINGPERMITf I FEEE: {(ecoG; (ELECT. I PLG.-. MECH'n.
Z) {.., ALTER DRAIM&VENTWATERMAll { fIISO} O3
"ULL
,O' I BACK-FLOW'PROTECT?DEVICE_ "
O O { DRAWS'FLOOR?ROOFLAREA COND)
FIXTURESS'PERT APP
F Z { GAS EA^SYSTEM ZINC 4..0 TSS }
(� • i "GAS EA�,SYSTEM OVER4,IEA 11 I
{ = INDUSTRIALIWASTEFINTER3
( ' LAWMSPRINKLERS_.1 INCSV.Bq..
f LAWN`SPR INKLERS:,OVER SIM.).) {
{ SEWER-SANITARY STORM/!EA.200WJ. { _ ZZ T✓✓
WATER°HEATER-W/VENT( ' I _
{ WATER ISYSTEMA•
{ WATERTREATING EOUIPP. {
{ ..;
MECHANICAUPERMITf J FEECT, f�
iJ ALTER Oft-ADD TO MECH1± 1
{ APPLIANCES - O
{` AIR HANDLING:UNIT IT0,10M)C.F M I1
AIR HANDLING UNIT(OVER 10p00CFM 11.E+1/] (� v
^' EXHAUSTIHOOD.(WITH-DUCT)I' { ... rLRIpYv
HEATING_UNLTIITOA00',OOOBTUII ." - { -
�j' -H EATING UN IT(OVER-100,000 B-T.U.1:1;
VENT)L'ATIO N,F AN,(Si N G LEI I - ;
" BOICERg COMP.f3 H:ProT.it OD,0008TU)1'
ROILERCOMP,Io.,,:loo 000 9TmiSEEIFEU SCH: ,
{ i
TOTAL.