22477 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINESQ POINT PEN ONLY
BuildingProed Identification 17 V��& I l pp_., PERMITNO.
Bunding Addren:,
O'1co Lb. p6�.i?.i� (I Wo. 22 A 7G G 4 I7
1ams: one: � A
/J,q-,Z /Ayo4&&yty Q/��� CITY OF CUPERTINO-BUILDING DIVISION.
can LI,No: APPLICATION I PERMIT �- I
• tee"^ /t- BUILDINGELWMCA PLUMBING-MECHANICAL CATEGORYCONTQO16
/h
A00hlt En Lk.N. SOV
a QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provWons of Chapter 9(commenc, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
1nense Is In WH 7000)of Dlvfect. the BuelnassandlerofeselonsCAdO,and my
license Is Section
7000)and effect. PANES
Liconn Clan Lk.T - -
CAVMW
Date Contractor UP TO 2DO ANMS
ARCHITECT'S DECLARATION 201-1000 AMPS
pkp�vv"OZs I understand my plansshae be used as public recoeds OVER1000AMPS SO.FT.FLOOR AREA S/SQ.FT.
S d�j Licensed Professional SIGNS ELECTRICAL 3(-t - 44107
<6 OWNER-BUILDER DECLARATION
SPECIAL CIRCUTE/M15C
ra(@mthatlamexempt 31.5,Bfromthe ConlractahLicensehw fort he
cuntyfollowing reason.(Section routto Butlnessand Pro(mba Code:My city or
TGSP.METFROR POLE INST.
p
county which regrto it permittomnsrequies themprovgdemsuch,0rto
S�
any structure detriments that
I-limage Extesueat to the for euchsofpermit e POWERDEVICES
k` floe a ilgnrtl detriment.La[ham he k licensed pursuant to the provisions of the
PQ1 t.n3 fthe Lkeonene law(Qu t.9Cm ).rth with Section 7000)o(Dlvl- VALUATION
3W�n R SWIMhENG POOL ELECTRIC
gen3oftheBusinesa and Pro(emloaCode)orthat heheampmthere(romand
G the bawls for the alleged exemption. Any violation of Sectlon 70715 by any OUTLET&S'WITCHRSSFIXTURFS ss•a ��.
applicant for a permit subjectethe applicant to a civil penally of not more it.. l `a,
five hundred dollars(§500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employe"with wag"as their sok SQJ-7' STORIES TYPHICONSTRUCTION
compensation,will do the work,and the structure to not intended or offered for So
sale(See.70K Busmen and Plans ba Cade:The Contractors Llnne law
rag don not apply to an owner of property who builds or improves thereon,and [(,'J�..1y7b.� 3f OCC.GROUP RFS.UNITS
EEEE who donswchwarkhmueVurmhrough hleownempleyees,provided that such
improvements are not intended proffered for sale.](however,thebullding m 00 Cal 1 TOTAL T CC 0
improvement Issoldwithinoneyearofmmplewb tis owner-bunderw---have
tl�yrd..of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE ELOODwNE � APN
any as owner of the property,am exclusively rontraning with Ilrenaed PERMITISSUANCE
/ t
tracmra to construct the project(Sec.70K Bwlnessami Profenlons Code: l
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilde or Improves thereon,and who contracts, for such p(ojecta with a FEE SUMMARY
cq➢I ctm(e)Ilmnmd pursuant to theCmmractors Lirense Law. BACK FLOW PROTECT.DEVICE
[_J I am exempt under See. B& P C for this reason
OUTSIDE FEES
Owner Date
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N
RECE3PT Y
WORKMAN COMPENSATION DECLARATION FTXTURFSPERTRAP SCHOOLTAX Y N
❑i hereby affirm that I have
a certificate
of cmnifi to self-ihemo or RECEIPT a
certl,lL b of Worken'Compewtlm lnsurmreorarertlFled copythereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK PER Y N
3600, # C.) RECEIVEM
Po11ry Y
Co�anGAS EA.SYSTEM-0VER 6(EA)
BUILDING DIVISION FEES
CctlBed
copy is herebyfurnished.the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEEZ�
Certlfed copy Is filed with the city inspection division. �1 •�i� (p �T�T
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID /7'T 'I 13/ `I-Ct77
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
Qhlasection need not becompleled lithe permit b forom hundred dollars
($IW)mlen.) WATERI�AT-FR W/VENT/ELECTR ENERGY FEE Y
I rectifying N the pertormanm of the work forwhich this permit Is Issued, 6
I shall not employ any person In any manner so a to become wbj)ct to the wATlRsysDTM/TaEAnNc "I-'17Yq(r.Z� "'� OOr QJ
Workers'Compensation Laws of Glifomia. Date PAID
O Z Applicant NEIVRFSIDI'NTIALPLMB. �Ff. Date R¢Lpi [#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensaton provisions of the Labor TOTALil a _
IN Code,you must forthwith comply wlthauch provisions orthb permit shallbe t t
7 deemed revoked. 13LIlLDING FEE
'�' •V�':
W o CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL Z Thereby affirm that there bamnslmctlm lending agency forth perform- TOTAL: 0 ELECTRIC FEE ,
arm ofthe work for which this permit b Issued(See 3097,CIv.C.) ' PLUM6-7,00
V 2 Leader.Name BING FEE
f QT
Under.Addrene Y, MECHANICAL PERMIT FEE
O0
Imrilfythatl have read this appncatlonand date thattheabove lnformatlm MECHANICAL FEE
Lsmrmd.7 agreeto comply with all city and county ordinances and gate law) PERMIT ISSUANCE LY/ FEES PAID:
IL
} relating tobullding construction,and hereby authorize representatives of this
H N city to enter upon the abovcmentioned property for inspection purpose. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an d keep harmlen the City of Cupertino Date Reaei t#
V against
liabilities judgments,cost dand expenses which may In any way.mme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a a at at Cl i coatp erre fthe a"in oft lspermlt.
WW L AIR HANDLING UNIT(OVER 10,000CR) CONSTRUCTION TAX
am fAr
Signa e o App " t on"actm EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA D UR NN
Will the applicant or future bu0dag lav an t e rhan Icazargo� HEATING UNIT(T0100,000 BTTp Dale Recti t#
material as defined bytM Cupertino MunlciA ode, ha)aler9.12,and the
0 YMd Safety Cade Sed iron 25532G)7 HEATING UNIT(OVER ID0,00)BTU) TOTAL:
Willtheapplicantor tore building rccupam use equipment or devices VENTILATION PAN(SINGLE RESIDE ISSUANCE DATE
which emit harardnus air contaminants as deflned by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
71 Y. Q No
have read the haxa ousmaterials requiremmis under Chapter 6.95 of MOILER-COMP(OVEd 100,000 BTU) PAID
the California Health&Safety Code,Sections 25505,25533 and 25537.I ,
undcrsland that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ_FT SEP aa• ^��
responsibility to amug a7r
ally the occupant of the roquirements which be met �a+�
prior to issuance ofa Cerificateof Occupancy. 1 `may
Ownerorauthorixedagent Date ISSUED
TOTAL
OFFICE COPY