21843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE'BALL POINT PEN ONLY
Ruildlna Ended Identification PERMIT NO.
Building Address: �T
�ao,3 5 /�da6WA_44 A4 ,L5 e,JAca 71,40• e- ISO/SZ 218 4 3
Uwnera rvame: / ''`` Phone: APPLII.A I IUN SUBMI I I Al,UA IL
FHye�F�9JLr/ Be7� o2jJ -, p:'C CITY OFCUPERTINO-BUILDING DIVISION
C MaROr'eNa(ry-��'/�.�7 �1 �/Ll{ejJ APPLICATION / PERMIT
-� • `'G` • L`3 r-15 BUILDINGELECTRICALPLUMBINGMFGHAMCAL� CATEGORY CONTROL p
'- Architect/Englueee Lic.No: - _ J
/j/t�'T,`,/}' �/J / , ( II ELECTRIC PERMI•F, � , •� FEE' •� I"I]BUILDING PERMIT INFO J
Addrcv:ZZO�S �.f�/�(�J/l!�—L.K, `VPC�• - F�l - PLUMB MIAH•ALDLI
PERMIT ISSUANCE
LICENSED CONTRACT CONTRACTOR'S ON o ICI 1 u
I Am L:]I hey Bcen erprovlalons of Chapter (mrrroxaoc- APPANCESRFSIDENTIAL JOB DFSCRN ingwthSMo n7(aX))ofDIv blon3 oftW BusnneandP feseonsCdx,and
my
beans,is In fu Affect. PANELS
License Class Lic.q 47 3/ 5
Pl.-U d'lFj•
Date r.moseror ��ITTTOZTAMI`q , '
ARCHITECTS DECLARATION 1201-I000AMPS
pZO I understand my plans shall be used as public records. OVERIOOOAMPS SQ.F7.FLOOR AREA
Licensed Professional I SLCNS ELECTRICAL
' OWNER-BUILDER DECLARATION
�i SPECIALCIRCUTT/MISC
;..,
following nRrmthatlam 31.5,8 sines Contnctsio sirens Law fort h• _
r oo following reason,(Section 7NL5,Business end Professions Code:Any city it or
r which requfires a permit torovtruct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
any stucture prior to its buance,also requires the applicam for such permit to
file a signed&atement that he k licensed pursuant to the Provisions of the _ POWER DEVICES
O w Contractor's Llcenm Law(Chapter 9(commencing with Section 7000)of Div1-
�OS slon 3 ofthe Businesaand Professions Code)orthat he b exempttherefromand SWIMMING POOL ELECTRIC I VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
appl].et fora permit subjects the applicant to a civil penalty of net more than)
live hundred dollars($.SM NEWRESIDEMIALELFCTR SQFI,� SfOfRES TYPE CONSTRIICTIONI
.• []I,as owner of the property,or my employees with wages as their sole
'tea compensation,willdothe work,and the structure beat intended or offered for
ci vin(Sec.70K Business and Professions Code:The Contractors License G
S� does not apply to an owner of property who Wilde or improves theme,and OCC.CROIIIa RES.UNITS who doessuch wark himself or through his own employees,provided that such
unprovereenta are not intended oroffered forvls.If,however,the W ilding or TOTAL:]
improvement issold within oneyearofcompletlon,theowner-bullderwi[I
the burden of proving that he did net build or improve for purpose of sale.). QTY, PLUMBING PERMIT ' I 'FEE ' FLOOD ZONE _ APN
LJ I,as owner of the property,em exclusively comractlng with licensed ,
contractors to construct the Project(Sec 7064,Business and Professions Code: ( POWITISSUANCE IJIM '
The Contractors License Law don eat apply to an owner of property who ALTER-DRAINk VENT-WATER RA) l
Wilds or Improves thereon,and who contracts for such ptojecta with a _
m,Bipctor(s)Ikenxd Pursuant to the Contractor's Llmnse law. BACK FLOW PROTECT.DEVICE I I FEE SUMMARY
LI I am exempt under Sec. B k P C for this reason I 911Talp.F lire I
DRAIN FLOOR 00$ I SANITARY V N
S
Owner Date R AREA,COND.
WOR KMAN COMPENSATION DECLARATION /' ^ -1 RECEIPT N
' ❑I here by affirm that I have a ceMRcate of coneent to self-inure,or a 6 FIXTURES.PER 77LV' I 1 xis I SCITOOL TAX Y N
t renlfimteofWorkeri Comper tlonly mnceoracenifled copythereof(Sec. CAS FA. INCA 1 R[: ER'FM
3800,Ub C.) I PARK FEE Y N
Policy RECEIPT#
Coco amp CAS EA.SYSIFM-OVER4(11A) I I BUILDING DIVISION FEES I
F_Cenlfied copy is hereby d with the I GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' �Certlfied ropyb(Iled with the city Inspection division. I
CERTIFICATE OF FXEM PT]ON FROM WORKERS' GREASE TRAP - I (PAID
COMPENSATION INSURANCE
(Thateedionneed eat becompleted Btheper tbfworohundreddollaml ]SEWER-SANRARY-STORM EA.20OFT. I 'Date Receipt# r
($IW)Onen,) WATER THEATER W/VENT/ELCCTR 7NERCY FEE Y N
I certify that In the performsem of lhew.ek f lrwhich this permit is bound,
I shall not employ any person In any manner so as to beromn subject to the -
WorkeraCompenneon Laws of Califomat.Datr WAI'GLI SYSTEM/TRPATING - PAID ,
Z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,your NEW RESIDENTIAL PLMB. SQ.Ff. _Dote RCCeipf#
should becomesubjad to the Workers'Compematloe provisions of the Laborl ' TOTAL: ]
Wir N Code,you mw at forthwith comply with such Provisions ortha permits hall he (BUILDING FFE �
j dnmee revoked. SEISMIC FEE
a O .CONSTRUCTION LENDING AGENCY '--�-I
IhercbyafRimthat thereata ronutmctlon lendingagencyforthaperform, TOTAL: ELECTRIC FEE �p
Z ante of the work for which that permit b bsued(Sec.3097,C1v.C.)
O O Iaader'.Nanx" - i PLUMBING FEE
LL F- t.nndcr's Addu•oo ' _ _ _ IQTY• . MECHANICAL PERMIT ;FEE;,,MECHANICAL'FEE
O I and ify that l have read this application and state that the above in formation _
O W scormd.l agree to complyieth all city and county ordinances and state laws) PERMITISSUANCE I FEES PAID:
>_ 0. relating to building construction,and hercbyauthorlurepresentaBvnofthis
F Z citytoenterupon lheabova-mentloned Property for inspection purposes. I ALTERORADDTOMECH.
V _ (We)agree to save,indemnify an d keep harMess the City of Cupertino Date Receipt#
age As t lla 164x,pdgmenIs A dexpenxs whichmayinanywayacane AIRHANDLING UNETITO 10,000CFM) I I SUBTOTAL:
again[ `d City In con noflM an tingofthisparmt.
�� ALRHANDLINGtIMT(OVERIg000CIT1) I I CONSTRUCTION TAX
e ,i
/ Signature at Applicant/Contractor to IXI-1A115T HOOD(W/DIIC7) I ,. ]CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WWlheapplica ntorfuture building ottupantstore or handle haaardous BEATING UNITOO 100,000 BTU) Date RCCCIDt#
matertal as defined by the Cupertino Municipal Code,Chapter 9,12,and the '
Hwlthand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) + I TOTAL: RI't.-w
❑ Yes, M No
Will the applicant or futurebuildingo pantuseequlpment ordevlces VFNIILATIONFAN(SINGLERESID) I hS$U/{NCE DATE
which coot hazardous air ronta Mnante as defined by the,Bay Are.Alr ^ll$-/aWd lYfLp:¢C
Quality Management DuMd7 BORER-COMP QHP OR 100,000 BTU)
4 Yes ; qNo
havcread earth ar Safety requirements under 6.95 of BOILER-COMP(QVQt 100,(100 BTU) F 999'1
the California Health building Safety Code, of come25505,ve a t and 25534. I /vv 1
uxprouindthat notify th, theoapant of a mgtdleoavea tenant that b key NEW REST DFN77AL MECIi. �,RF
r riot to bal anc f a Certificate sate of Occ pa requlremenls which most be and co [h l . t• i
prior to Issuance ofa Ccrtillcata of Occupancy. � � I lF1LV a,•f 'OfIM•• .el' /-�
Owner or authorvcd agent Data ]ISSUED BY
_TDTAL:I
OFFICE COPY