22257 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ect Identification T PERMITNO.
Building Address:
i o i s/ 4_,C_6-4-A✓o/L/ / Z
2257
one: APPLICATIONSUMITTALITA717
I 23 L CITY OF CUPERTINO-BUILDING DIVISION
C no- r8Name: uc.Nmo APPLICATION / PERMIT
�azl
'5_9 � �
�. Archit /En '` f� py�o,_� BUfLD]NGELECIRICAG['LUMBINGMFAHAMCAL CATEGORY CO
r ''f� LL'.y KJ� S444) 7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO -
Address: C'�' p' �- -y //�� � 7foj PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION 0 El
I hereby affirm that l am licensed under provblons of Chapler9(cnmmenc- APPLIANCES-RESIDENTIAL I JOB DESCRIPTION
ingwith Sedion 7000)of Dlvisior3ofthe Businessand PmfesslonsCode,and my _
licenseisinfunomp%effect PANELS
Licenas C.T)Lic.I
Date—�se l-/�/Fa, /((i-j —CaMnnor
ARCHITECTS C31 ATION 201-I000AMPS
ce 7. I understand my plans shall be used as public records. - OVER 1000 AMPS /SQ.FT.
O SIGN5ELECTRICAL N � �
� Ej Licensed Professional
z w OWNER-BUILDER DECLARATION - SPECIALCI(CUIT/MfSC
7F' Iherebyaffirm that l am exempt from the Contractor's License Law for the -ODao� •
following reason.(Section 70315,Business and Professions Code:Any city or a
TEMP. ORIOLE INST.
county which permit pedt loconstmct,alter,improve,demolish,or repair �` 1�
4 < anystm=mpriortoltsissuancgalsorequimtheappbantfo wchper tto POWER DEVICES
p�y'o.c.O file a signed statement that he b nrensed pursuant to the provisions of the
0 3 Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi-
^ SWIMMING POOL ELECTRIC
,.�Oa s:on3 ofthe Business and ProfessionsCode)orthat he Lsth
exempterefromand VALUATION
x�F-.t• �2 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSSWITCHESFIxi S I L+ �0 CDs Oc
<� applicant for a permit subjects the applicant to a civil penalty of not marc t ban
c,y O five hundred dollars(SSW. NEW RESIDENTIAL ELECTR SQFT. - STORIES TYPE CONS'TRU'CTION
�2
L1 z ❑I,as owner of the property,or my employees with wages as their sole a compensation,wW do the work andthe structure is not intended or offered for
5�0 saleCSec.70K Buainessand Profoanons Code:The Contractor's License law
don not apply to an owner of property who builds or improves thereon,and - OCC.GROIII' RFS.UNITS
doessuchworkhinaelf orthrough hisownemployen,provided that such
Improvements..not Intended oroffered forsale.If,however,the building or TOTAL:
Improvement baold withinoneyearofcompletiogtheowner-Wflderwill have -
th�u rdeo of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE - APN
L�L as owner of the property,am exclusively contracting with licensed. PERMIT ISSUANCE
'
contractors to construct the project(Sec.704q Business and Professions Code:
The Corhactor's License law does nor apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pcojeds with a ALTER-DRAIN&VENT-WA'T'ER BTA) _
111L;t;actor(s)licensed pursuant to the Contndor*s License Law. FEE SUMMARY
01 am exempt under Sec R& P C for this reason BACK FLAW PROTECT.DEVICE OUTS I OF HE IS
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owner Date RECEITM
WORKMAN COMPENSATION DECLARATION �.�S�.�P SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have o luso ate of consent to copy
thereof ora RECER'T X
38000cabC.) rkers'Compevatlonlnsurance ora certified copy therso((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.I RECEIPT#
Polity p I CAS EA.SYSTG4-0VFR d(FA)
Co civ J BUILDING DI VISION FE CIS
rcertif:ed copy hit hereby famished. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division. G L�
CERTIFICATEOFINEMPTIONF'ROM WORKERS' CREASEIRAP, PAID G
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200IT. Date ReCel t# is
(this section need not be rompleted If the permit bfor one hundred dollars
(S1W)mless.) WATER HEATER W/VEJT/ELLCTR ENERGY FEE Y_ N_
I certify that in the Performance ofthe work forwhich this permit Is issued, .
I shall not employ say person in any manner so as to become subject to the WATER SYSILM/TREATING
workers'Compensatkm Lawsof Californle.Date PAID
ZO Z Applicant NEW RESIDENTIAL Ii SQ.FT. Date Reevi [#
O NOUCETO APPLICANT.If,after making this Certificate of Exemption,you
shwld become subject m the Worker'Compensation provisions of the Labor TOTAL:
Ln Cods,you most forthwith comply with such provisions or this permit shall be
W rD
> deemed revoked. BUILDING FEE
CONSTRUCTIONLENDINC AGENCY -SEISMIC FEE /x
0. o Iherebyaffirm that there Is a construction lending agency for the perfornF TOTAL: ELECTRIC FEE
Z ance ofthe workforwhlch this permit is issued(Sec.3097,CIv.C3
O O lender's Name - - PLUMBING FEE
LL 1— Lenders Addmaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythat[have read thisappBationand statethatthe above Information
O W bconect.I agree to complywith all city and county ordinances and state laws PERMITLSSUANCE FEES PAID:
T d relating to building construction,and hereby authotlze representatives ofthb -
F 2 city to enter upon the abovnmentioned property for Inspection purposes. ALTFRORADDTOMECH. Da[e. ReeelPt#
e)ages to save,indemnify an d keep harmless the City of Cupertino
L) agar' `c)ZlEiea,judgmenas,routs and expenses which may in anyway cera AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
as, cast said City in con f the granting of this permit CONSTRUCTION TAX
/ AIRHANDUNGUNII'(OVER10,000CFM) -
h
SOil—
ignature ofA Bart/Co tactor D e EKHAUSTHOOD(W/DUCT) CONSTRUCFION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Willtheapplicant orfflurebuildingoavpant storeor handle hazardous HEATING UMTOO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
Health and Safety Code Section 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Yes , IJ No
Will the applicant or foram building occupant use equipment or devices VEN'DLATION FAN(SINGLE RESID) ISSU ��1TE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHIP OR I0B000 BTU)
4Yn IF��No JUL b 2. 191
have read the Faun usmaerialsrequimmentsunder Ghapter6.95of BORER-COMP(OVER 100,0008N)
the California Health&Safety Code,Sections 25505,MS33 and 75534. I
understand that tithe building dons not currently have a tenant that it is my NEW RESIDENTIALMECH. . SQFI #4sa„ Ly
espcmibility to notify the occupant of the requirements which most be mM - co� 0110""['_'--'
prior to issuance of a Certificate of Occupancy.
Owner or authorimd agent Date I ISSUED
IOTAL. �T
OFFICE COPY