22582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMTTNO.
Building Address:
' IDIS 1 GDN Pfz►V .y
vera ame:W �s 1#ZL$ CITY OFCUPERTINO-BUILDING DMSION A
• Contractor's Name: Lie Nm APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBINGMEC MCAL CATEGORY CO.
"no
BUILDING PERMIT INFO
hit ct En : .
no fD QTY ELECTRIC PERMIT ''FEE
Address:
PERMITISSUANCE
LICENSED CONTRACTOR' DECLARATION
I lurebyrdfurrithiti arrillcomed under provisions of C9(comumc
Ingwlth5ection7000)ofDivision3ofthe Business
usinesnd ProfessionsCode,and myAPPLIANCESREADEN'T1AL jofvl]SRIPMN
license is In full force and effect PANELS Q�pn y�y�
ense/ �Lic. "Il_ _- _w ( l • { ly„ �
DKL
� �X 1. ContraRor aFCX+/I�.� UP TO 2DOAM5
4•/ ARCHITECTS DECLARATION OVER
AM I
rs03 I under&tand my plansslaBb nspublic records. OVER 1000 AMPS ✓Q.FI.1L RAAEA $/SQ.1T.
Licensed Pro fesslo OWNER- SIGNSELECTRICAL
�<re 1 ECLA RATION O
rn 1'n' SI'ECIALCIRCUIT/MLSC
H � I berebyason.(that on 7BLIexempt fromBusiness
a Contractor's Licenses Code:LawAny for the
p9� following reason. 7m1.5,Business and Professlone Code:Any dtyor TEMP.METER OR POLE INST.
P a county which requires a permit to mnstruct,alteq improve,demolish,or repair
Ne��� anystmu mpriortoisimance,a6 requimstheapplicantforsuchpert tto POWBRDEVICES
ryL file a signed statement that he is licensed pursuant to the provisions of the
'Contradors License Law(Chapter 9(mmmencin with Section 7000 of D)vi-
w Pt 8 ) SWIMMING POOL ELECTRIC
O sion3of the Busmen and Pru(essbruCode)orthM hebemm therefromand VA U TI
the basis for the alleged exemption. Any violation o(na penalty
of7�15'S W / 180
,FSv'iC.) the licant basis
ape alit leged excts the emption. Any viot to ation pe mltyo(�E',•••,,JV!^ �- HESFlX7TIRFS s L
E $ five hundred dollars($500). 0 if
N'BOV FSI AL
7 G ❑I,as owner of the property,or my employees with wage as' r s �'�' STORIES T1�E CONSTRUCTION
compensation,will clothe work,and lhestruchre Is not intende ffVandJo��er�
5 p
to(Sec.7004,Business and Professions Code:The Contractors Licenselaw I
$ does nM.pply to an owner of property who builds or improvm th�eo d
c-$^ whodo wchworkhm Yorthroughhis wnemployem,provideB/lf�rtt 'GROUP RES.UNITS
Improvements am mt Intended oroffered fwmle.IL however thebuilding ozvl 1;70 '
Improvement issold within oneyearofcompletion,the owner-builderwill have
tigIsirdenof proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PER IT FEE FOODIDNE MIN
Lr L as mucor of the property,am exclusively Business
a ed
dProing with licensedCode: PERMIT ISSUANCE � j� 44M
contractors to conswd the project(m exclusively
ively con and Professions Code: - X
The Contractor's License taw does not apply to an owner of property who ALTER-DRAIN kVENT-WATER TEA)
Wilds or Improvm thereon,and who contracts for such pt,ojocts with a FEE SUMMARY
,,P_or,ad r(a)licensed pursuant to the Contracture License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
DRAINS TUDOR RODF,AREA,GOND. SANITARY Y_ N
Owner Date RECEIPT X
❑I here M
WORKAN aNSAT10N DECLARATION FD(TURES. TRI SCIi00L TA% Y N
I have by affirm that have a certificate of consent to self-Insure,w a REGEmr X
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA SYSMM-1 WC4OUTLEIS 1 PARK FEE Y N
3800,lab C.) l
Policy u 1 a 5 ; 7 3 4 —Q f RECEIPT X
G y___.M R GAS EA.SYSITM-OVER4(EA) BUI LDING D I VIS ION FEES
ertlfiedcopy is hereby Ish GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CedBied copy is filedhere with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID_k-7 77l
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.100FT. tC RCcc' 1#
(This se tion need nae be comploted if the permit Morons hundred dollars
($100)or len.) ENERO'41F
I ceor leshat M the performance of the work for which this peat is Issued,
I shag not employ any person In any manner eo as to become subject to the WATTS SYST M/TRFATING
Workers'Compensation laws o(Cal1(omla.Date PAID
plicant
Z Q NOT7CETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. - Datc CMM t#
should become subject to the Workers Compensation provisions of the Labor OTA :
CCN Code,you most forthwith comply with such provisions orthis permit shall bo BUILDING _
W > deemed revoked.
fA
CONSTRUCTION LENDING AGENCY SEISMIC F11-
CL Iherebyaffirmthattherelsaronstrudion lending agency forthe perfore, TELECTRICIjEE
M ZO ante ofine work for which this permit is Issued(Sec.3097,Civ.C.)
(� Lenders Name PL N •E
LL H Lender's Address QTY. MECHANICAL PERMIT -FEE — PGE
O W Icertifythatl have read this application and statethatthe above information - -
ismrrect.I.greeto comply with all city and county ordinances and state laws PERMIT ISSUANCE F $
IL
} relating to building construction,and hereby authorize reprxsenf it oftho,
F U) city to enter upon the above-mentioned property for inspectlonpurposea, ALTEIORADDTOMECH.rtino D Rkel t#
to save,
demnify and
of
I..I
against liabilities,judgments,costs andexpenseswhich ess tma Cin anywapaceroe AIRIiANDLINGUNIT(TO10,000 CFM) P
R pence r y r I SUBTOTAL:
against said Clt In consequence of the granting of this permit.
LL.,/rY AIR HANDLING IINR(OVER]O,000CRI) ONSTRU ON TAX
gwtore of Applicint/Contractor �r�Date' ' EXF1 USTHODD(W/DUCT) CONSTRU ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllca nt orfutum building occupant store or hand le hazardous HFATING UNIT CM F00,0D0 BTU) Date Recel t
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Fkalth and Safety Cade�ia,-�S�ection 75532(a)? HFATING UNIT(OVER 100,000 BTU)
Yet
❑ No
Wil the applicant or futurebv.11ding occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hszvrdous air contaminants as defined by the Bay Area Air -
'� Quality Management District? - BOILER-COMP OHPOR 100,000 BTU) -
F-1 Yes No
haee read mN the haYee -] materials requirements under Chapter 6.95 of BOILER-COMP(OVER IM,”BTU) PAID the California Health h Safety Code,Sections 15505;75533 and 15534.1 P
understand that lithe Wilding does not currently have a tenant,that it is my NEN RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. NOY 18 -1gg1
Owner or author0nd agent Date155I1ED6 ,9 •, Is
OFFICE COPY
i
ADDITIONAL PERMIT 'FEES.
BUILDING PROJECT IDENTIFICATION VALUATION
ACCREAS
OWNERS
' NAME FEE SUMMARY '
PHONE
CONTRACTORS- - BUILDING
NAME
vC.NO PLAN CHECK
CONTRACTORS - - :FEE
AOOREss .. -
PHONE ' SEISMIC FEE
CITY. ELECTRIC PERMIT`
UTLETS SWITCHES RECEP ELECTRIC �t�!!J
LIGHTING FIXTURES _ - ' PLUMBING
APPLIANCES-RESIDENTIAL -
\1 PANE LS MECHANICAL.
1MECHANICAL.. -
`� SIGNS +^:e��.,r}"^
OTAL
SIGNSTRANS..
SPECIAL CIRCUIT. T?
�e - .PERMIT VALIDATION
EMP.METER OR POLEJNS. _ P pPo B
MOTORS SEEFEESCH:
0 SERVICE CHANGE
Z'Z fQ.d
F 4 TOTAL C 0 1`99
OF S NCE DATE
.'W DTV. . .-' PLUMBING PERMIT.- -FEE- SLOG, SLE �H6D7 MECN.
COL.33 ❑ '❑p [� ❑
ALTER-DRAIN&VENT-WATER(EA.)
f, 0 —BACKFLOW PROTECT.DEVICE _
LLU' DRAINSFLOOR,ROOF,AREA COND. `
a FIXTURES-PER TRAP
N
GAS-EA.SYSTEM_11NC.40UTLETS
V GAS-EA.SYSTEM-OVER 4(EA)- ['� -
_ INDUSTRIAL WASTE INTER. iJt�Ll
LAWN SPRINKLERS-I INC 5 V.B.
- LAWN SPRINKLERS-OVER 5(EA.)' q :
SEWER-SANITARY-STORM EA.20011/' FS- �
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TQIAL
CITY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH. _
APPLIANCE'
_ AIR HANDLING UNIT(TO 10=C,F.M.)
AIR HANDLING UNIT(OVER I QOW C.F.M.)
EXHAUST HOOD(WITH DUCT) :
HEATING UNIT ITO 100,000 B.T.U.) '
HEATING UNIT(OVER 100,000 B.T.U.) '
VENTILATION FAN(SINGLE)
BOILER-CDNP Q H.P.or I00,DOO B.T.U.)
BOILER COMP IOvd 140,000 FIT UI SEE FEE SCH. .
TOTAL