22218 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pea.0 Identification EMMET NO.
Building Address: / 22218
3 1.J0 IY�CAE�
.era one: A A
TOMWPot6N CITY OF CUPERTINO-BUILDING DIVISION
Contracteors Name: Lie.No: APPLICATION / PERMIT
LI.LJ a Lwwa� 6L."" 1 BUILDINGELFiCMCALPLUMBING-MFG LAICAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PFRMITISSUANCE ❑ o ❑
LICENSED CONTRACTOR'S UECLA RATION
Thereby dflrmthat lamlicensed 3oftheunder provisions o/Chapter 9 eadonsCoclearnenc API'llANCESRESIDENIIAL ]pg DESCRIPTION
Been.h ionI.full7000)ofDivfeet' !the Budneuand Tho/esslonaCode,and
my
Ilunse la In full force and d(ect, PANELS ` yN.—t
I,Icensc Class Lic.# r�� h,S l Wil l `��
Date E -1-qI—Contractor _GLs4t UP TO0AM
ARCHTECPS DA0
PS
rat 0W70 T .(understand rtry plans shall be used as public recordOVER T WO AMPS 4/SQ.IT.
s. t lI
�a7 tl�j Licensed Professional SIGNS ELECTRICAL I "
OWNER-BUILDER DECLARATION 11'�J
SPECULCIlZCNT/MLSC
f, Thereby of@ruthot lam exemptfromthe Contractors Llcensa Gw(or Ne �/�
fallowing reason.(Section 70315,Bu.inen and Profevions Code:Any city or
F�I"'u� countywhich requeesa permit becotutruct,alter,improve,demolbh,orrepair TEMP.METER ORIOLE(NST.
`' .a anystrucwre prior to its Issuance,ahorequires theappliant forauch permit to POWER DEVICES
c file a signed statement that he 6licensed pursuant to the providers of the
Conl.Rors Llceve Law(Chapter commencin with Section 7000 o(Divl- VALUATION u,Fn ( pt ( g w ) SWUIMING POOL dECTRIC
OGG sbn3ofthe Bu.lncadand ProfeniamCode)orthathebexem therefmmand
t- H the bass for the alleged exemption. Any violation of Section 7Q1L5 by any
IEE O
applicant for a permit subjects the applicant toocivpenaltya re
l penalty of not mothan
OUTLETSSWITCHESH)(7URES
$ five hundred delta.E$500). NEWRESIDFNIIALELECTR SQXT. TYPE CONSIitUCT10N
p, ❑I,as owner of the property,or my employees with wages as their sole
�7Q compeneatloo,willdo the work,and the structure s not intended or offered for
O sale(Sec.7044,Rudeness and Professions Code:The Contractors License law
5$ don not apply to an owner of property who builds or improves thereon,and OCC.GRON' RFS.UNITS
does such work himself or through his own employees,provided that such
improvements an not intended proffered for sale.If,however,the building or TOTAL:
improvement issold withinoneyearofcompldt mtheowner-bu0derwBl have
th rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with licensed pp(MITIESUANCE
contractors to conaeuct the project(Sec.7044,Buslnesa and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN A VENT-WATER(EA)
Wild. or imp.thereon,and who contracts for such plojeM with a FEE SUMMARY
cgIlt(actor0)Bocnsed pursuant to the Contractor's Lt...Law. BACK FLOW PROTECT.DEVICE
IJ 1 am exempt under Sec B 4 P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEII'IN
WORKMAN COMPENSATION DECLARATION Fl%TURES PER TRAP SCHOOL TAX Y N
711I hereM
by affirm that I have a certlflate of consent to se141ndure,ora RFGEBxI'N
certifinteofWorkers'Compenaatlon I....cracernfkd copy thereof(Sec. GAS FA.SYSTEM-1 INC OUTLETS PARK FEE Y N
3800,UbC.) — RECEIPT
CPolicyPolicyN GAS FA.SYST[ht-0VER<(FA) BUILDING DIVISION FEES
C. ny
CrmUed copy Lai hereby ftme.hed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
F-1Certifiedcopy s filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA 200117. Date Recti (#
(Thisuett..need not be completed if the permit 6 for one hundred dollars
($100)orless.) WATER HEATER W/VENT/Q.FGTR ENERGY FEE Y N
I camiythat In the performance of the work forwhlch rm
this peit isissued,
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workeri Compensationlaws of California. Date PAID
OZ Applicant NEW RESIDENTIAL LMB. SQFT. Date Recti t#
Z O NOTICETO APPLICANT.IL.fter making th6CertlfkneofasenEtio ,you
Fshould become subject to the Workeri Compamation provisions ofine Labor TOTAL:
cc N Code,you must forthwith comply with such provblom or this permit shall be BUILDING .aO
W > decreed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby affirm that there Is a cerotmction lending agency for the perform ELECTRIC FEE
7 Z soon
o(the work!or which the permits6smd(Sec.3097,Clv.CJ
TOTAL:
O O Lcndcrb Name PLUMBING FEE
F Lender.Add.. QTY. MECHANICAL PERMIT FEE
LL U 1ucifythatI have read thisappilationand state that the above information MECHANICAL FEE
O W scoured l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE PEES PAID:
} 1 relating to building construction,and herebyauthortza expresentativnofths
F W o.3to enterupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
z :(WO agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V aga Wtlfabillties,judgments,caasand expenwswhtch mayln anywayamme AIRHANDUNGUNIT(T010,080CFM) SUBTOTAL:
xg I acid Cityi nxquena o(the gnntingofthi.permit AIR HANDLING UNIT(OVER IO,OW CI.1.11 CONSTRUC'MON TAX
CONSTRUCTION TAX PAID:
Signatvrsof liant/Contra Date EXHAUST HOOD(W/DIKT)
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcaut or tutu re building oceu pant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety CadSectione Sion 755320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
yes No
Will the appllantor tore building occupant use equipment or devices VENTILATION FAN(SINGLE RF.SID)mir
ISSLIA�E,DATE
which emit haeardoacentaMvnts as defined bythe Bay Area Air 1p� �6'
Quality Management District? BOILER-COMP 0HPOR 100,000 BTU)
4Yes n No
havcrcadthe huar�ousmaterials requimmentsuuderChu pier 6.95of BOILER-COMP(OVER 100,0W81U) SIIA1 31991
the Gllforn6 Health&Safdy CWe,Sectiom25505,25S33 and 75534. I JUN
understand that if the building does not coreently have a tenant,that it s my NEW RESIDENTIAL MECH. EQ.FT.
responsibility to notify the occupant of the mqui em ants which most be met pp�yµ/s„��jr�
prior to Issuance of a Certificate ofOccupancy. r 01 el QVIN{I
Owner or agent Date TOTAL: ISSUEDBY:14 ��ILUCL�
OFFICE COPY
0ca7-ov, — W< s T cv,4- V:TM' L'�o
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3070 r/�+ boor lf%4-e
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APPROVED
IN ACCORDANCE WITH THE CITY Ot
CUPERTINO CODES AND ORDINANCE! jI
q ! I
GATE
SIGNED CCZh ` I 'I
j
This set of laws and specifications M
Al it
be kept on the job at all times and it is r I ii
lawful to make any changes or alteratijI
on same without written permission frllr li;I j
the building Dept., City of Cupe,hno. it �' f
The stamping of this pan -nd specificariq�i1I
SHALL NOT be lied to pe mit or tc be !�'i
approval ;f the violation of any provisiGlif
,f nv 0,h 0 d nance or State Law. i
EMU
��r JUN s
SLDB.C41Y DE CUPERTINQ
D4B3 wb�t e