22595APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
- PEFtMITNO.
.22595
Building Address:
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ane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-ELECTR1Cp pLUMBINGMECHAMCAL
APFUCATION SUBMITTAL DATE,
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1° °N "" 11A- fc.N.:
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CATEGORY
CONTROL M
' .Bed/Engineer•. - Lk. N.
QTti ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address (, 1
L Tr V •
PERMITISSUANCE
CEEC PLUMB NTTTR
❑ _ .❑ ❑
-
LICENSED CONTRACT OR' DECLARATION
I hereby affirm that l con licensed under p lehonsaf Chapter9(commenc-
Ingweh Sction fo00)of d offan3olthe Buelnessand PTO(eesloneCade,and my
license is In (u8 for dd(ect f�
License I WILT. SC.0 a 11
Date Contractor 940,�
APPLIANCES RESIDENTIAL
PANELS
c
�]O�B DESCRIPTION
"s•:n U� J/
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T
ARCHITECS DECLARATION
I understand myplarnsh.Bbeusedeapubllcreenrd°. d
201-IOOOAMPS
/T� �L�
;
OVERIWOAMPS
SQ. Fr. FLOOR AREA $/SQ. Fr.
SIGNSELECTRICAL i
Licensed Professional -
hereby OWNER -BUILDER DECLARATION
IwingraBbmthat lam31.5, Bexempfrom the C PreflaesLleene: Law fm thefollo
murtyngreuon.g irectfoermitt,Budness and Proprove, Code: Any city it
anystm hkhrequlreaapermit ,co.mViatter,Improve,demoBah,orrepair
[(crouch permitto
any atudure pater[eitekat he
file .signed datement that he h licensed pursuant m the provlelona of the
pursuant to
Contractor's License Law (Chapter 9(corrmiencing with Sect1on70W)of Divi-
Mon 3 ofthe Business and ProfragmeCode) or that he is exempt thercfromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
fora permit subjects the applicant to a civil penalty of no mare than
five ed
I, as owner of the property, or eery employee with wage as thele sale
comps as owmollenhepr.
rompeneaHon, will Businethe ss
and fess..nd structureois h. c. mended or offered for
dale (.Sec. apply to alno andfpmperq Code:The or Impctors thereon Law
doe not such oen owner a( property who Wilda nemporimprwvidedthereon,that and
who dceseuchworkhimself arthrough Msownemployees,providedihatuchOCC.
Improvereontsare not intended oroffered fmsale. If, howevcr,thebullding or
h sold whthln om yeamfcompldioo.the owner-bullderwlll have
Bii;Lysude of proving that he did not build or Improve for purpose ofsale.).
LJ 4 a° owner of the property, am exclusively contracting with,llttnxd
contradoes to construct the project (Sec. 7094, Business and Professions Code:
The Contractees License Law doe not apply to an owner of property who
Wilde or Improves thereon, and who contracts for such pRo)etts with a
cq➢Ifador(s)hceneed pursuant to the Contradoe. License Law.
LJ I nm exempt under Sec. B 4 P C for this mason
D '
. e.tea
/YtJg t
.
Y. -
VALUATION
VALUATION
$I'ECLIL CIRCUIT/MISC b
TEMPMETTRORPOLEINBT.
POWER DEVICES
SWIMMING ]VIOL ELECTRIC
OUTLETSSWITCHFSFIXI'f1RES
NEW RESIDENIIAL ELECTR ,Fp,
SQ
STORIES
TYPE WNSTRUCTTON
GROUP
RFS. UNDS
. TOTAL:improvement
Q174 PLUMBING PERMIT FEE
PERMIT ISSUANCE -
ALIIIt-DRAIN&VENT - WATER (EA)
FLOOp ZANE
pPN.
'
BACK FLOW PROTECT. DEVICE
FEE SUMMARYOUTSIDE
FEES
Owner- Date
DRAINS FLOOR ROOF, AREA, GOND.
FDS' PER TRAP
SANITARY Y— N_
RECEI'rk
-. d;7—WORKMAN - COMPROATION DECLARATION
.- I hereby a((Irm that i have a certificate of consent to self -Inure, or a
cert3 h otWorkeee'COm eationlroumnmmaedlfkd thereof
3800, Lab C.) roPY 4eec.
Policy I
SCl{OOL TAX Y N_
AECIID'rR
GAS EA. 9YSTEM-1 INCA OUTLETS
PARK FEE. Y ' N
RECEIrr N
Com any -
Codified copy is herebyte city
Codified copy h filed withh the ci
e city inspection division.
GAS EA, SYSTEM -OVER 4 (EA)
CREASE/INDUSTRL WASTE INTERCEPTOR
'1 BUILDING DIVISION FEES
PLANCHECIC FEE '
GREASETRAP
'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'(TMseedionneed notbecompleted tithe permit h(orone hundred dollare
PAID
Date Recei t91
SEWER -SANITARY STORM EA 200FE
($]I0)mfyth In
Illnor thatoythe
any person
I shall not employ any person f any manner eo as to become abject to the
W any hewmk forwhich beco eermlthho the
Wmlicant mpemalon laws o(Cali(omia. Dare
Applicant
NOTICEco APPLICANT:e ager makingteslasM11 Preis Exemption,you
should
ou=ame eurthwiteck the Workers' such
Coda you =at forthwith comply with each provbbdo orthh permitsha118e
permitofts Lab be
deemed ked. � �
WATER HEATER W/VENT/E-ECIR
ENERGYFEE Y N —
D
PAID
Date Recei t#
WATER SYSTEM/TREATING -
NEW RESIDENTIAL PLMB. SQ.PL
�- TOTAL:
--
�B DING FEE
_ TOTAL:
CONSTRUCEION LENDING AGENCY
erform
perform-
I hereby affirm that there is aionstuction lending agency for the hu
.see
.nee of the work for which this permit (sed (Sec, 3097, Civ. CJ
Lender. Name
Lendre.Address
Icrrtifythatl) ereadthiaspppimtoriandstatethatmeabovehnfoiamlon
hcorred.I agreeto comply with all city and county oMlnanms and state paws
relating to building cregrudhon, and hereby authodxe representatives of this
dM
city enter above-mentioned property for inspection purposes.
Me) agree to save, Indemnify an d keep harmless the City of Cu pertmo
against liabilities, jugywen ata dexpens, which n wayacerue
againstsNdC co� s i eo t gran g Tthis n
SEISMIC. FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE - -
-
PERMTTISSUANCE 2t 65�
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TO 10,ODOCFM)
MECHANICAL FEE
FEES PAID:
)Rte Recei tic
P
SUBTOTAL:
AIR HANDLING UNFf(OVER IO,000CFM)
CONSTRUCTION TAX
SignaluremAppliran ontrador Date
RDOUSMATERIA DIS LOSURE
Will the spill tm(uturebuBdNg occupan morhandlehazmdoue
material as defined by the Cupertino Munhtlpal Cods, Chapter 9.12, and the
Heallhand Safety C ^xdmn25532(a)I -
❑ Ye �] No
EXHAUST HO TO M/DICT)
CONSTRUCTION TAX PAID:
Date - Recei tic
HEATING UNIT 100,000 BTU). ��
HEATING UNIT (OVER 100,000 BTU)
ITOTAL:
VENTILATION FAN (SINGLE RESID)
ISS TE
"}a_''j1YAiiPs
-
.. T�
���,al�—�
ot '(j,171A�—IV�aLQ—_l71
Will the applicant or future building occupant use equipment or devices-
which qm t h.eardoua at -contaminants as defined by the Bay Area Air
- 'aTty Managerseat Distrid7
Yen ,- �No
read thetas Det mode, Se requirerrenb 5533 and 25534.1 of
lite Califorund arstanniaat if th&Safety Code, Sections25505,25533have
died that n tifyhe the ing occupant not a currently m nts tenant, That R h my
a tend, than[
responsibility of the requirements which must 6e met
reporoiiss ityce notifytheiate
BOILER -COMP OFT' OR 100,000 BTU)
BOILER -COMP (OVER 100,(Np BTU)
NEW RESIDENTIAL MECH. SQFf.
prior to issuance ofaCertifiwte of Occupancy.
of
��../y���� �/
ISSUED 8Y: �— •'
Owner or authorized agent Date
TOTAL; O a
OFFICE COPY. --
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