22630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ea Identification PERMIT NO.
Bailding Addrcn: 22630
/�� 2 G7EDAe Tie�e 7
c
Mr9 Name:
G S ACITY OF CUPERTINO-BUILDING DIVISION /X eZ�`
. Comrades'sKernel Lie.No: APPLICATION I PERMIT YJ
ArcFltect/Englnrer. Lk.No: BU(LDINC-ELECnUCAI.PLUMBINGMECHAMCAL CATEGORY F6
720L M
QTY ELECTRIC PERMIT FEE
Ep, BUILDING PERMIT INFO
Add.. PERMIT ISSUANCE l CY ❑ It JI ❑ �j
LICENSED CONTRACTOR'S DECLARATION 1-151 Lp
IMithSMiott7000atlam Bcensed under provlgensofCadoesCdr,and nc APPLIANCESRESIDENffAL JOB PESO ON
(nonseISenn force anDlvfect. fMeBugneuand ProfeegonsCode,andm 6 I(,TC•(1, `^
limeslCU fuB(one ended(.#. 1 PANELS ���
License Clam Lk.M
Date Contndor
UP TO 2DO AMffL—
ARCHITECT'S DECLARATION 2I1-1000 AMPS
aO ZZ I understand my phrc
m.hall be used as public meds. OVER IODO AMPS SQ.PT.FLOOR AREA $/SQ.FT.
E od i Licensed Professional SIGNSELFLTRICAL A L E D '
<6 OWNER-BUILDER DECLARATION j
1n] S!'ECIAL CIRCUIT/MIST
i ZI-"'cal [hereby offlrm that[cant eaempHromthe Contractor's Llrenee Law for the p /T
pp following rcazan.(Sedlon 7031 S,Business and Profession Code:My city or 'v' p u T E
D'y F., TEMP.METEROR POLE[NSC.
�� rountywhlre rcqukma isacantommmquirestheapmvgtfor such,ornpalr
q' < R .
any atrudurcstatementahat he
pursuant
to the pnovisc ns,of t e POWER,DEVICES
f5 U Rk a erre.statement that he h r 9(cod pursuant it the provhbm of the
3w Con3oftheusees Law G SWIMMINGIUOLELECTRIC DA
�1b0� .lon3o(lhe Buelneas and Pro@aebmCode)orthat heh emmptthercfromandJA 11O�
the bash far the alteg d exemption. Any violation of Sedlon 70115 by any OUTLETSSWITCHESFIXCURES
appbmntforaper taub)edatheappllcanttoadvilpemltyofnmm mt)un
five hundred dollars(5.500). NEW RESIDENTIAL ELECTR
a owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
mpematlon,wilt do the work and thesuucture knot intended or offered for
ole(Sae.7054,Runabouts.nal Profession,Code:The Contractors License Taw
oea not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
whorl such work himself Na own employees,provided that such ��yA/��
improvements are not Intended oroffered forsale.I(,howevepthebulldingor TOTAL: s W
improvement hsoki within omyvarofcompidiory the owner-W dderwdl have
1knliirden of proving that he did not build or Improve("purpose ofsahJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
[j ,aa owner of the property,am exclusively contracting with licensed pptMlT ISSUANCE
mntndon to mmeo lmd the project(S70K Business and Professions Code:
The Contractoea License Law does net apply to an owner of property who
Wilda or Improves thereon,sad who contract, for such p(ejem with a ALTER-DRAINhVEM-WATER @N
c+ act"(il lmnsei pursuant to the Contndor'a License Law. FEE SUMMARY
IJ I am exempt under Sec. B k P C for this maven BACK FLOW PROTDCT.DEVICE Q.trc.11a MR
DRAINS FLOOR ROOF,AREA,COND. SANITARY . Y N
• Owner Date RECEIPT�
WORK MAN COMPENSATION DECLARATION F.�S PER TRAP SCHOOL TAX Y N
❑1 hereby affirmWorkers'
that I have o Insur ate of consent to op thereof(Sa RECEIPT I
certificate abC Workers Campemation Wunna"arertlfkd copythereo((Sec. GAS F.A.SYSTEM-1 INCA OUTLM PARK FEE Y N
Policy
# CJ RECENT#
I'ol(ry#
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Cc m
CertiAyfied copy h hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR CKFEE
CertUed copy h(fled with the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE ' gLyr,ER-SANITARY-STORM FA.300p1'. Date Recd t#
(ThUsedion need not be completed tf the permit b foronehundred rs
dolla
(S10D)erless.) WATER FNATERW/VENT/ELECTR ENERGY FEE Y_ N_
I ndrtitythat N the performanceo(thework ferwNch this penult is Wuad,
1 shall not employ any person In any manner soas to become subject io the WATER SYSTEM/TREATING
Wmken'Compen®tlan lawaof California.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. QFC. Date Recel t#
Z O NOTICETO APPLICANT.If after reakinglhb CertBkte
aof Ecnnptlan,you
should become subject to the Workeri Compematien provisions of the Labor TOTAL:
N
Code,you must forthwith comply withauch provbiom orthh permit sball be
_ BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDINGAOCNCY SEISMIC FEE
CL aMZ Ihfthy..Brmthatihhthamr ti. onledingag7,Cio. .) perform- ELECTRjICFEE
Z Lenderthe work forwhich thio permkb blued(Sec.3097,Civ.CJ TOTAL:
L) O Lenders Name PLUMBING FEE
H Lander'.Addm.s - QTY. MECHANICAL PERMIT FEE
OW Iearli(y that l have read thio application and gate that the above information MECHANICAL FEE
1 Is correct.I agree to comply with all city and muntyordlnances and gate laws L PERMITISSUANCE l FEES PAID:
>. N relating to building construction,and hereby authorize mpresentativeeafthis
fcity to enter upon the abov nrxctioned property for Wpection purposes. ALTMORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of CupertinoDate Reeei t#
V
against rugs iabilltks,judgments,rus aexpenses which may in any way accme AIR HANDLING UNIT(TO 10,ODO CFM) aD SUBTOTAL:
agai mid ty In co.seque the tiogof Permit. CONSTRUCTION TAX
ll—,?Z-71 y� / AIR HANDLING TINCT(OVER I0,000CFM)
f L CONSTRUCTION TAX PAID:
Signature o(ApplHAZA onOUS Date EXHAUST HOOD
HAZARDOUS MAnRIALS
cupautDISCLOSURE
Will the ell end bor y
future rtildingoicipan ode, hhandle hazardous HEATING UNIT(TO 100,000 BT71) Date Recei t#
material as S f&y C y the Cupertino Municipal Code,Chapter 9.13,and the LL
Health and Safety Cdc Section 75533U)? BEATING UNIT(OVER 100,000 BTU) TOTAL: 7 VV
❑Yes P No
Will the applicant or arum bcildingoccvpantuseequipmemordevinds VENDLATION FAN(SINGLE RESID) jIjIIANCE DATE
Mich emit hazardous ab conlamtmnls as defined by the Bay Arca Air J.1♦�T/vAft
. lity Management District? BOILER-COMP OHPOR 100,000 BTU)
YYes No
?have read the hazardous materials mqulrements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) v
the CLllfomia Health k Safety Code,Sections 25505,25S33 and 75534.1
understand that if the building does not currently have a tenant,that It h my NEW RESIDENTIAL MECH. SQ.FT.TOTAL: � L/f(, �/j
responsibility to out Uy the occupant of the requirements which mu at be met w /y
prior to hsuanre ofaCerilBate of Oce panty. vu`\\`
Poo
Owner or authorized agent Date - - ISSUED By. CQs•
OFFICE COPY