22298 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building 7 m'ca Identification PERMIT NO.
Building Address:
22298
L3 l �'F� VISI-D-I�
A A
CITY OF CUPERTINO-BUILDING DIVISION /
cn ctn'sN LIjr No: APPLICATION /PERMIT (0 L 1.
eUILDINGaF)CTRICA4PLI3MBINC-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lk.No:
r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add L2--- P, ^ Q PERMITISSUANCE ❑ ❑
LICENSED CONTRA SDE( ATION
I hereby affirm that lam Bcensed under mvBlons ofChapler 9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwhhSection force ofd effect. ofth aaeand ProfesslonaCode,and my
license la In full force and effect. PANIE[S
License Class Lk.#
Date Contnaor —UP TO 2DO ANUS
ARCHITECT'S DECLARATION 201-1000 AMPS
7 Iunderstand my plans shall be,used as public dards. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
- � IN
Licensed Profcssioal SIGNS ELECTRICAL
�¢ OWNCR-BUILDER DECLARATION SPECIALCIiCUIT/MISC
F, J Iherebyanna.(haton 7031mptfmmthed Protections Code:
Law fort he
TOZ;:p fo0owing reason.(Section 70315,Business and Pro(embv Code:Any city carp MEIIIt OR POLE[NSI'.
ul rountywhich requima permit tocnmtruct,alter,improve,demolbh,orrepair
g����Q anystm=mpdortolta ancgalsorequtrntheappbmntforsuchpemtto POWER DEVICES
E U Ole a signed statement that he Is licensed pursuant to the provisions of the
Ow Contractor'sLicense Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC -J_ VALUATION
f,�0e sin.3ofthe B..inew and Pmvsd..Code)orthat he is m
exempt thercfroand
p a.•s]] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIIF-SFIXTURFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five I,as o nerdolars;of
a pro NEW RESIDENTIAL ELECTR SQFf. STORIES TYPECONSTRUCTION
O 7� meas owner will
the property,or my employees with wages r thele sok
C 7.6 compensation,willdess and Pr andthes Code:Ts Contranded oroQcmedfor
5�n sale(Sec.7004,Business and Professions Code:The Contraaols License Law�j, 5$ does not a pply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work hfmself or through his own employees,provided that such
Improvements arc not intended oroffered forsale.If,ho seven thebulldingor TOTAL:
Improvement bseld withnoneyearofcompldkNtheowner-bu0derwRl have
I th,e*rden of proving that he did not Wild or bnprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APNr
L_j L as owner of the property,am exclusively contracting with licensed ppSg(R ISSUANCE
contractors to construct the project(Sec.7064,Business and Profenlons Code:
Tlu,Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contractsfor such py)eas with a
co¢,➢�t(Iaaor(e)licensed pursuant to the Contractor'.Licenae Law. FEE SUMMARY
L�1 BACK FLOW PROTECTDEVICE
am exempt under Ser" B k P C for this reason .
OUTSIDE FEES
DRAINS FLOOR RODE.AREA,lbND. SANITARY Y N—
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIM(30L TAX Y N
QI hereby affirm that I have a certificate of consent to self-Insure,ora RFGER N#
certlfiateof Workers'Com Honlnsuranceor cealOcNcopythercof(Sce. CAS IA.SYSTTEMd INC.4OUTLETS PARK FEE Y N
Polis Isis C.) / spy RECEIPT#
Po11ryY h O, xC GAS EA.SYSTEM-OVER4(EA)
� y BUILDING DIVISION FEES
e Oedcopy Lshere fumian . �_ GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city inspection division.
CERTIFICATI OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200E 1'. Date Recti t#
(This section need not W completed if thepermit isfor one hundred dollars
(s100)or leas.) WATER HEAT6t W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performanceof the work forwhich this permit isissued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California.Date PAID
O Z NOTApplIC m NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z O hoolCETO es objeAM:eW.rkmakinglhb .ti.. ateof Eaemptlon,.you bo
should become aubFct to the Workeri Compeaa1lon provuloa Orme Labor TOTAL:
S N Code,you res at forthwith comply with such proeisWaor this permit shall be BUILDING FEE
deemed revoked.
W� corvsrlMurnory LENDING AGENCY SEISMIC FEE L
a Thereby afflrmthat there is a comataalon lendingagency forth perform TOTAL: ELECTRIC FEE
Z an"'
of the work for which this permit ct issued(Sec.3097,Civ.C.)
O O I"ender'x N.. PLUMBING FEE
LLQ~ lander'a Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l certifythat l have read thisapplicationand statethatthe above Information
S Isconea.lagreetocomplywithalletyand county ordinan laws PFRMTISSUANCE FEES PAID:
�. N relating to Wilding corataalon,andhcmbyauth.Z mativnofthla
Z city toentcrupon above.mentloned Property for ion purposes. ALTERORADDTOMECH.
(We a c t save,Indemnify and keep Tar a City o pertino Date Receipt#
V against mens,costsend expense. mayI y yaccrue AIR HANDLING UNIT CrO 10,000 CFM) SUBTOTAL:
agaimU yin roes the gran' this pe t
AIRHANDLINGUNTT(OVER10,Oo0CFM) CONSTRUCTION TAX
2! CONSTRUCTION TAX PAID:
S' sore a(AppBant/ ontractor ate IXHAUST HOOD(W/D[JCl7
HAZARDOUSMATERI ISCLOSU E
Will the applicant or futurebuilding pa fit store or handle hazardous, HE UMT(TO ifA,000 BTU) Date RCCCi t#
material as defined by the Cupertino Municipal Codq Chapter 9.1 2,and the -
HeanhandSmfctyCodeSection 25532(a)7 FIEATING UNIT(OVER 100,000 BM TOTAL: t
F1YnNo
L+-�,ur VENTILATION FAN(SINGLE RESID)
Will the.ppllam or future Wilding occupant use cquipnr•m w devices VENTILATION DATE
which emit hacardous air contaminants as defined by the Bay Arca Air
,Quality MaagemeneC No BOILER-COM?OFlI'OR 100,0a]BTU)
F?ye.
`(have.vc No
read the Nazar cases materials requircrncnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 0TV) a `^
the Callfomla H4c ealth Safety Code,Sea lora 25505,25533 and 25534. 1 0V G•,1 I� Q
understand that if the Wilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SO.Fr. / P
mpoalbWty to notify the oaupa of of the requ lmments which must be met /t;a
prior to Issuance of a Certificate of Occupancy. Q
Owner or authorised agent Date ISSUED BY: %1
TOTAL:
OFFICE COPY