22504 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERhIT NO.
Budding Add ress: - 22504
one:
� � �D GLfsillGl A
CITY OF CUPERTINO,BUILDING DIVISION
Can°"raeto !moms: ie—N. I
APPLICATION I PERMIT
Architect/Ggine - L Na: BUILDING-ELECnUCALPLUMBING MCCHAMCAL CATEGORY CONTROL I✓L �O
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IQ ,' , ELECTRIC PERMIT �,. ?�i'CC'. BUILDING PERMIT,INFOI" '
Address: Z/ 2�i',N00' IYIV GT ,•,
rERnnTlssuANce QO
LICE 5 O AfIcTN
I '
Ihembyaffirmthat[am Rcenu underpro Wonso(Chapter9(mmmm APPLIANCESRESIDEMIAL JOB DESCRIPTION
Ingwith Sedion7000)of Divisim3of[he Busime and PmfnsionsCodem ,andmy,
license Is In full forand died. PANELS ,
LicenseCurse Lt.# - - `^
DataContranar DVK ��I•-(��/�}.�
ARCHITECTS DECLARATION OOAMIPS
07� .Iuntlentand my plaru shall be used as publlcremrds:r OVEROVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FL.
Fi Licensed Professional SGNSELECTRICAL �]r�V 7'{ p Z
G�6 OWNER-BUILDER DECLARATION C V -lY
k., Ihereby a BE that Ison exempt from the Contractor's License Lawfor the SPECIALCI2CUIT/MLSC .
7
9 countywreason.(Section7015,Bashersand
r,Imprve, Code:Anyctpir
TEMP.METQt OR POLE INST.
K� arystywhkh rcqulrcsa permits,mretecuirestheapmvgdennlbh permit
to -
q xnyatsigned pdorm Its that
he in lice sed pursuant t ilthe provisions
of ithe POWER DEVICES
filed signed rtatemeLa that he is(Chapter 9(mm pursuant to the pro 7000) of the a', +
3'
Contractor's License Lawradess9(rommandat he is Sectioxampt herefomand
H slon3oftheBusinnsand ProfevbnCode)orthathciseumptthere(comand SWIMMING POOL ELECTRIC V/A,�..L..,�UA1\TION (�
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any, OUTLEISSWITCHFSFIXMiES
applicant fora permit subjects the applicant to a civil penalty of not Peers than
five hundred as ed dolbn he pr). NEW RESIDENTIAL ELECTR SQ.PT. •.STOW TYPE CONSTRUCTION
L°�n ❑I,as owner of wfll othewperly,or my employers with wages r thele sok -
rompeneatlon,B.shar.an ork,and thes Code:Th not Intended or offered for
O
.In(Sec.apply
to anow and f property
rope ty Code:The ContractorsthemeLicense Law
3$ whodossucbtoanownerofprough hisoWilds nempor improves yees,povidedrmryand - OCC.GROIIP RES.UNITS
whodoeaeuchworkhlmsel(orthr0ugh hbownemployen,provlded lhatsuch
Improvements are not intended oroffered forsale.If,however,thebuiiding or " TOTAL: 3
icon ro�ave pntis50' within oneye -compldbrylhe owner-budderwill have
ncfpmvingthathedldsmbulld orimprove forpurpose of salty. QTY, H, PLUMBINGP,ERMIT7.' �! ',FEE' FLOOD ZONE APN
L as Owner of the property,am exclusively contracting with licensed I PERMIT ISSUANCE �Z
tr rs to construct the project(Sec.7034,Business and Profenlom Code: s(X/ -
7he Con rsdtrs License Law does not apply t0 an owner of property who
buALTER-DRAIN&VENTWATT[((EA) '
•
Wilds or improves thereon, and who comrade d - -e for stub pwje
e with • CD
,,Il➢.t.4{��nor(e)Itmnmd pursuant to the Contractors Lies.Law. ,, ,i .�,1 I.1, FEE,SUMMARY"
IJ i am exempt under Sec. B&P.0 for this mason BACK FLOW PROTECT.DEVICE rq
` DRAINS FLOOR ROOF,AREA,COND. +-t�
SANITARY Y N OUTS I DE �
• Owner Dale
WORKMAN COMPENSATION DECLARATION RECEIPT#t y Fp(TUR[_S PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a lose me of consent to self-Insurs,ora —1 RPGID'I#
certificate C.WorkOn'Compereatlonisuuranceora ceni(kd copythereo((Sec. 'GAS EA.SYSTEM-1 INCAOUTLETS PARK FIT Y ' N
3BOQ Lab CJ
Policy GAS EA.SYSTFM-OVER 4(EA) -BUILDIEIPT NG DIVISION
Com er - BUILDING DI VISION FEliS
Certified copy is herebyfurnished.the city
-• GREASE/INDUSTRL WASTE INTERCEPTOR PLANCNECK FEE
❑Certified copy is filed with the city inspection division..
GREASETRAP Vy7
CERTIFICATEMPE IXEM PN N FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SAMTARY.S'TORM EA.XIOIT.,- Date Recel t# ,
(Thlesese.) need no[be completed I(the pemJ[isforoo hundred tlollars P
(Si00)Oify that
- WATERHFATFRW/VENT/ELECTR ENERGY FEE Y N e-G,
Icertlfy that Nthe performance o(the work forwhlch this permit is issued, `r I
1 shall not employ any person In any manner so n to become subject to the WATER SYSI•FM/TREATING
Workera'Compenwtlon Rous of Callfornla.Date PAID
C) Z Applicant
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL FILMS. SQ7T. Dale Recei t
Z
should become suI to the Warkers'Compereation provisions of the Labor - TOTAL/
cc N Code,you must forthwith comply with such provisloru orchis permit shall be _BUILNG '
EE
lV > deemed revoked. - _
CL CONSTRUCTION
cme LENDING AGENCY SEISMIC FEE—
D
themIsIsissnlendingd(Sec. agency 7,Civ. .) perform, TOTAL: ELE •'E v
Z once of the work!or which lhls permit islssued(Sec.3097,Civ.C.) •� � .�•
00 Iandees Name i' , - t PLU BI F a- a(alcrD
LLF LendersAddress - QTY. MECHANICAL,PERMITI 't ,iyF-E'... MECF [ FEE M
OW Icertifythatl have readthisapplicationand statelhattheabove lnformati0n
C iscorred.I agreem complywith all cityand munlyordlnanme and state laws ' PERMTTISSUANCE. ��.,CD.rFE $ ID:'
relating to building comouctlon,and hereby authorize representatives of this , .
F 2 city to enter upon the above,manti ned property(or Inspection purposes. ALTFRORADDTOMECH. a _ RC
(We)a ve„Indemnify an d keep harmless;the City of Cupertino
againat Bile. d me ,msmantl expenses which may In anywayattroe 'AIRFIANDLINGUNTE(T010,000CFM)' $DBTOTA
ag.i ai c cryence ofthe granting of this permit. - -
V6 I6 qI AIR HANDLING UNIT(OVFR I0,00a CFM) CONSTRUCTIONTAX
g
cost/Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS MATIiR1A Ex DISCLOSURE '
Will the applies cat orfuturebullding occvpantamre or handle haurdous HEATING UMT(T0100,000 BTU) Date RCC t#
rtuterial ae defined by the Cupertino Municipal Code,Chapter 9.1$and the yi -
Healthand Safety Co de Sedlon25532(a)7. l HEATING UNIT(OVER 100,000 BTU) aC-V TO L1
❑Yes - ['�No
Will the applicant or futme bcllding occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) �pp�x1CC DATE
which emit hazardous air contaminants as deflated by the Bay Area Air
Quality Management District? BOILER-comp(3HP OR 100,000 BM
4
Yes V.Na tie 1519 _
havercad ealth'a oet Code, boons 2menb5533 an 255M.I of BOI.FR-COMP(OVQ(100,0008M n
the California Health'&Safety Code, Stela 25S05,25533 a tenant,
25534.1
understand thatn notihe fy
the ingoccupant
pant of the rthe equir haves tenant,that it Is mybe
NEW HFSIDENDAL MECFi. SQ.Pf.
responsibility issuance
of.Ctheicatecntccupmaqulremente which most be met --
prior to Lssuanm o(a Certificate ofOmpanry.
Owner or aulhonred agent Date fl -TOTAL: ISSUED BY: V
4.
OFFICE COPY