22464 (2) APPLICANT TO FILL IN INFORMATION-WITHIN RED LINES— USE BALL POINT PEN ONLY
BuildingPr.ed Identification eu I'1 0 PERMITNO.
B"„Y8 Addrese: 1t�0 a-'lJ 22464
!O oo ���p f3Wp seals-c-I�
woesI tea''"" rvyT one: - A
p L.� �-c+►�4 L CITY OF CUPERTIN0.6UILDING DIVISION
. eon Lie.No: APPLICATION / PERMIT
ArN tett/Engineer. BU)LDINC-MMTRICAL-PLUMBING-MECHANICAL CATEGORY COb'a7ROF.NOO
Lk.No bb
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.: a. PERMIT[S6UANCE (�Sle
LICENSED CONTRunder rDECLARATION ,K�} L�
Ihereby d(trmaatlamlkn3ofth. erprovblona.fCssionsode,anenc- APPLIANCESRESIDENTfAL JOB DESCRIPTION
inerse lsetion70m)ofdeff,on3ofNeguelneseandProfesdonaC.de,and.
Iicenm bin tuft farce and dfott. PANELS S H F1
License Class Lk.• r,
Date ContraRor
ARCHITECTS DECLARATION IDI-1000 AMPS
rcO ZZ I understand my plane shaft be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 6/SQ.FT.
�(/ Licensed Professioml SIGNS ELECTRICAL I �,�/Ck V 1,
�< OWNER-BUILDER DECLARATION $4,E-CIALCIRCUIT/MIST
7 I hereby affirm that l am exempt from the Contractor's License Law forthe
following reason.(Section 7031.5,Business and Profeailons Code:Any city or
county which rcqulreea permit to ronstrutt,atter improve,dennWh,.rrepalr TEMP.METER OR POLE INST.
anyatmmm priortola bsuance,aborequlrea/heapplicantfm such permit to POWER DEVICES
O Ilk a signed statement that he is lkeruM pursuant to the proisims of the
Contratoes License law(Chapter 9(commencing with Section 7000)of Dict- VALUA'DON
°i len SWIMMING FOOL ELECTRIC
SOS thesiobasis
fo the alleged
Professions Any violation f axem)rt therefrom and :-✓-�:�
6
the bash for the alleged jeemtheap My violation of Section 70315 re any OUTLEISSWITCHFSFUITURES (]
appgcantar aperMt°ubj tithe appllcanuoa civil penalty Mnot morethen a"` �I �_C _� 1' _0 IPG71"—)
five hundred as owner of the ON. NEW RESIDENTIAL ELECTR SQFf. STORIES ECONSTRUCTION
[]I,as owner of the property,or my employees with wage as tbek sok
< compensation,will do the work and the structure is not Intended or offered for
O �to(Ser-70K that.and Pmfemlom Code:Th.C.rdned.e.License law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.DNTTS.
who does such work himselforthrough hleown employees,provided that such
Improvements are notlnknded oroffered formic.I(however,lhebuiWing or TO
improvement haold withinomyearofcompleion,theowner-buflderwOI have
th;*rden of proving that he did not bund or improve for purpose of sale.). QTY; PLUMBING PERMIT FEE FLOOD ZONE AP
N
LJ I,as owner of the property,am exclusively contracting with licensed pp )T ISSUANCE I �a+h -
contractors to combrut the project(Sec 7044,Business and Professions Code: lL .
The Contractor's Lkv
ee Law don net apply to an owner M property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such projectx with a FEE SUMMARY
cptor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
gR(bI am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT=
WORKMAN COMPENSATION DECLARATION FO(TIJRF.S PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a certificate of consent to opythemc ora RECEIPT a
cetlBcab of Worken'Comperuatlonlnsunnre ora rertBhd copythereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
Polis Isis CJ RECETT#
C. X GASFA.SYSTEM-OVER4(EAI
Com any BUILDING DIVISION FEES
coated copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKII�a'pp"(�aRQ/�0�
etRied copy h filed with the city Inspection division. pZ$'C/Lte(a,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP P/kI D'l1.'3jQr -1
COMPENSATION INSURANCE SEWER-SANITARI'-STORM EA.700FT. Date RCrnI t#
(TMaeectlon need nor be eemplted Bthe permit bfor one hundred dollars
(E700)or lcssJ WATER HEATER W/VEN7/ELECTR ENERGY FEE Y N
I certify that In the performance of thework forwhkh this perrniIssued,is ued, .�s Q
I shall not employ any person he any runner so at to become subject to the 6.
WATER SYSIIIN/TREATING
Workere'Compenmtion Lova of California.Date PAID
ZZ Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Rerni t#
NOTICE TO APPLICANT:If,after making thin Certifkateof Exemption,you
O
Hshould become subject to the Workeri Compensation provhlons of the Labor s� 4,'l TOTAL/ _ t
N Code,you moat forthwith comply with such provisions orthb permit shalt be c-"'zj0 ug Gia U G
W j deemed revoked. 5 ^]. _I,t, `� On SEISMIC FEE'FEE ���� - p-1 (
G CONSTRUCTION LENDING AGENCY j 'I
CL Ihembya(&.that therebpco, tmciionlendingag7,Cio. the petomm TOTA ELECTRIC FEE Q 10
0 O once ofthework(orwhkhthb permith Wued(See 3097,CIv.CJ
Lender's Na. PLUMBING FEE
LL h= Landes Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Z /^
W Icertlfythatl have read thbapplicationand statethat theabovelefomution
O
CL bcomet.l agree tocomplywlth all city and county ondlnancesand state laws PERMIT ISSUANCE ' FEES PAID:
N relating tobullding construction,and hereby authorize representatives ofthts
city to entero on the above-mentioned property forW ion s ALTER OR ADDTO MECH.
1' Y ` y P P pP1h' I p"rFOBe' Date Receit#
— (We)agree to save,Indemnify an d keep harmless the City of Cu Fenton P
against liabilities,Judgments,cote a M expenses which may In any way sews AIR EIANDUNG UNIT(170 10,000 CFM) SUBTOT —�
ggaJ 1 1 Inwyyj f t Chia permit.
7drl ,� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCnONTAX1719 W6
Siv
lgmtureo Appllex 'IContra or r 00 LAUST HOOD(W/DUCT1 CONSTRUCTION TAX PAI
HAlARDO SMA A B
Will the applicant or future ild g a sea. or handlehazardoua HEATING UNIT(TO 100,000 BTU) Date ReCC{ t#
matarialas defined by the Cupertino Must ode,Chapter 9.17,and the
Health and Safety Code Sodlon 75532G17 HEATING UNIT(OVER 100,000 BTU) k
❑Yes No
Will the applicant sur lure bcilding..p.m use equipment or devices VENTILATION FAN ISINGLE READ) ISSUANCE DATE
which emit harardousalr contaminants as defined by the Bay Area Air -
• Quality Management District? BOILER-COMP OHP OR 100,0%10 BTU) PAID
4Yea ❑❑No
have read tbe harallous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 FIT U)
the Ca llfom Is Health k Safety Code,Set Ions 75505,25533 and 25534.1 ppea� .a .a a�
undersa nd that if the building does net currently have a tenant,that It is my NEWRESIDENTIALMECH. SQFT. MAR 11 199/
responsibility to really the occupant of the requirements which must be met ` � '4sR�^,/
priorto issuance of a Cetifcate of Occupancy. G CITY Ur CUPtntIl�-
Owner or authotred agent Date - ISSUED B
�a s ani
TOT
OFFICE COPY
~ CITY OF CUPEE2I'ITIO PROJECT WORKSHEET
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• CITY DATE IN: C[IA REVIEW #:
CONTROL #• G 6 00 Mik DATE IN:
PERMIT #• CMA DATE OUT•
RECEIPP #• RECHECK #1, DATE IN:
VALUATION: DATE OUT:
CMA FEES:
RECHECK #2, DATE IN:
--------------------------- DATE an:
DOCUMENTS RECEIVED: DATE CLEARED:
INI R#1 R#2
Plans 1 2 3 1 2 3 1 2 3 CHECKED BY: INT R#1 R#3
Specs 1 2 3 1 2 3 1 2 3
Energy Calc 1 2 3 1 2 3 1 2 3
Soils Rep. 1 2 3 1 2 3 1 2 3
PC Response 1 2 3 1 2 3 1 2 3
Refer.Plans 1 2 3 1 2 3 1 2 3 PHONE CAIS, LOG DATE/TIIE/RESUI(P
Other 1 2 3 1 2 3 1 2 3
• PROJECT NAME:
ADDRESS (INCLUDEg�pp l
75
AMU=, ENGINEER, DRAPTPERSON: PROJECP DATA:
USE/SCOPE >
NAME: OCCUPANCY GROUP
CONST. TYPE
PHONE: FLOOR AREA/STORY
ALICIMENT AREA
CONTACP PERSON FOR THIS REVIEW: ENERGY MEPHOD
CONTACT VIA: PHONE MAIL (CIRCLE) AUTO.FIRE SPRNnR
NAME CURRENT CODE:
88UBC, UMC, UPC, 87 NEC
COMPANY
ADDRESS:
PHONE
•
FORM-CMA(BLDG5)