22214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PEMITNO.
Building Address:
0L-).-3 N�wo� �, X30 22214
urs e:mone: ..
�`bo p,k_ �DIQ6 h'� CITY OF CUPERTINO-BUILDING DIVISION q
centralo Njnr: 16 APPLICATION /PERMIT
%O—UUti !7 BUILDING-ELECTRICALnUMBING-MEC MCAL CATEGORY COh'TRO}^p'C'1
Architect/Fngineer. Lk.N : I07�
QTY ELECTRrCPFRMJT FEE BUILDING PERMIT INFO
Addrome PERMITISSUAN W ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby atfirmthat l am licensed under provisions of Chapter 9(commenc- APPLIAN ESTE L ]OB UPSCRITTON
Ingwith5cnion]DOO)of Dlvlsion3otthe Businemand Profe•slonsCode,and my
liana b In full forceand effect. P
License? Lie.# \�
Date / Contractor 1
ARCHITECTS DECLARATION 1-1000A.MP5
�7 I understand my plana shall used as public rernrds. AVERIflai"AlVP, SQ.Fr.FLOOR AREA $/SQ.FT.
0b a100� .LQCfi7
Licensed Professional SIGNS ELFGTRI L ,
OWNER-BUILDER DECLARATION SPECIALCIR T/ML5C
I hereby affirmthat l am exempt framthe Contractors Llan Iawforthe
p following reason.(Section 7W 15,Business and Professlans Code Any city or
FTEMP.METERORPOLE INS"r.
E4� countywhich requiresa permittocomtruci,altegtmprove,demol6h,orrepair
aoystmeture prlorto its bsuance,abo requlrcstheappllcant for such permit to POWER DEVICES
1 file a signed statement that he is licensed pursuant to the provisions of the
Caaractoes License Law(Chspler9(rommencingwith Seelon]ODO)ot Divi- VALUATION
sion3orme Businessand ProfenlomCWe)orthahe6ewmptthemfmmand SWIMMING POOL ELECTRIC _
the basis for the alleged exemption. Any violation of Section 7m15 by any IOUTLETS-SWITCHES-FIXTURES . g(•'I' OOOf(no
applicant for a permit subjects theapplkant to a civil penalty da nnnm than
w $ five 1,as o nerdolof the pr. NEW RESIDENTIAL ELECTR �pltyYy ' TYPE CONS'1RUCTION
7¢ ❑Lasowner oftheproperty,ormy employees with wages as theles ole iL_. U
sale IS,, 0K BusBotheworkand ere,Grade:The
Intended ormmoffered Lfor
sale(Sec apply to a now and fTaesbm Code:The Cuntraaore IAceme law
docs$$ whorl apply toanownerolproperty his wromsoyce,prndedthe anduch saaax
O RFSMrr5
wprovement am khimselfedorosgh hlsowne.If,ho ever,the building
`
Improvemcntsarenalnte node tuff d for mpletile.theoweveq ilderwdl have TOT
tp idenntbsoling thinonc id nat build orioprove frpuroserwillhave
t Meno neer of the pro dldna exclusively
efacting of ofcense QTY. PLUMBING PERMIT4APN
LJ 4 as owner ser the Property,am See 0K Iltity contress ed ro with licensed PERMIT ISSUANCE
z contnctom eo mmW Licct ense
Lawproject(Sect a p apply
to an owner
Pf property
Cade:
The Goor improves
es the law does eta apply sect an owner a Property who ALTM-DRAIN k VENT-WATER OW
c t or Improve thereon,and who contracts for such p(ojects with a FEE SUMMARY
cgIlt as m e em td pursuant See othe Contractor's License law. OUTSIDE FITS
1—J 1 am exempt under Sec. B &P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y_ N_
Owner Dae RECEIPT N
WORKMAN COMPENSATION DECLARATIONtoIfns �.�SI'ER TRAP SCIIOOLTAX Y_ N_
❑1 hereby a(fimn ththatce
1 have a rtlBcate of consenttto eel!-Iure,or RECEIPT N
renificate ofWorken Compematlonlmuranre ora renifled ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y— N
3800,Lab C.I
xEE rr a
Policy N CAS F.A.SYSTEM-0VER p(EA)
Cam ny BUILDING DIVISION FEES
nified ropy 6 hereby tumbled. GREASE/INDUSIRLWASTEINTENCE'TOR PLANCHECK FEE
Certified copy b filed with the city Inspection division. I� /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID`j�f 1L
COMPENSATIONINSURANCE SEWFR-SANRARY-STORM EA.20017. Date RCCCI t#
(This section need not he completed If the permit 6 forona hundred dollar
(SIMI or Icm) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I mmlythat In the performance of the work for which this permit is issued,
I shall net employ any person In any manner ro as to become subject to the WATER SYSTEM/TRFATlh'G
Workeri Compensation Laws.f Calilomla. Date PAI D
Z Z N07ICETO APPLICANT:If,after making this CertBkateat Exemption,you licant NEW RESIDENTIAL PCMB. SQ.FT. Date Recei t#
0 should become subject to the WmIums''Compenaatlon proleemotthe Labor TOTAL:
N Code,you rust forthwith comply with such provbiom orthb permit Asti be BUILDINGFE
2 > domed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
1L I hereby afftrmthzt there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
M Z once of the work for which this permit b Issued(Sec.3097,Civ.C.)
02 Lenders Name PLUMBING FEE
LLI— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Iceri that l have read th6a hcattonand natethat theabovetnformat[on r�
O W 6comect.Iagree to comply with act city and county ordinances and 9telaws PERMIT ISSUANCE L FEES PAID: `--'
Y 6 relating to building construction,and hereby authorize representatives ofth6
W city to enterupon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino 1 DatC Receipt#
V
against liabilities,Jadgmente,maxima expenses which may In anywayaavue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid City in neequence of the granting of this R permit. CONSTRUCTION TAX
pP /
—Iel AIR HANDLING UNIT(OVER t0,000CFM)
Si wmrc o(A Ica ontraaor 4fL//y/ Y to CONSTRUCTION TAX PAID:
IXHAOS'r HOOD(W/DIKT)
a0ifA
RDOUS MATERIALS DIS OSU
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IOgODO BTU) Date Reeei t#
material as defined by the Cupertino Municipal Cod,,Chapter9.12,and the I,
fkalth and Safety Coder�a--S�ection 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL. "La.
❑ Yea 1-1 No
Wllltheapplicantor((tare building occupant use equipment or devices VENTILATION LAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the pay Area Air
Quality Management District] BOILER-COMP DIIP OR 100,IX9 BTU)
Yli Fa No
Thaveread the h�Ou maedabrequlrentarsunderChapter6.9Sof BOILER-COMP(OVER 100,000 BN) r �llLu
the Ca Illinois health the b Safety Code,Sea fares 2550.5,have
a t and 2:539.1
e undentand that if the occupant
eta currentlyrequirmnts which that it mat NEW RESIDENTIAL MECH. �.FT.
responsibility I.islltyte of.Certificate
of et the requirements which must be coed JUL � n9l
p prior to lauanceaa Cenllkate of Occvpanry. (J��. o t�9`�Qs
Owner or authorized agent Date INyaay ,J•TOTAL:
OFFICE
OFFICE COPY