22021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building 1•mert Identification PERMIT NO.
Building Address: 22021
/O.2 S9 9 /NS I-d 12+P G
Ttw �. ma: Phone. AI'I U(A IIUN budINU I AL OA
1 J�X sGA46—Z 132 CITY OF CUPE'RTLNOLBUILDING DIVISION ` ��
;^ Contractor's Name: LmO.N ' APPLICATION IPERMI�
AIFR-L•."'A J01"A _ ZLo -.T q f BUILDI NG-ELECTRICAL,MUMBINC-vrcClA(ICAL CATEGORY CONTROL
Arcy nett/Engtnrer. Lie.No: - / J
SOUS �t1L4l uV Qz-�QYI ELECTR'C,P'ji T� fFE.' BUILDINGPERMIT;INFO,
Address:�( un GalloC/Sy[}�/+4L41f ax+r) r T u b��
LICF.NSF.D CONTRACTOR'S DECLARATION L�7
I hereby affirm that l am lkensd under provisions,of Chapter 9(commem, ESRESIDENTIAL JOB DESCRIPTION
Ingwlth Sedlon70W)ofMvision3of the Butinem..d Profe.siom Code,and my a -
Iicenssleln(uB antl dfed. JPANE'S
License Cl O /y L
Date�C ARCHITECTS �' f V t
ARCHITECTsc DECLARATION tu i card 1.1
7O Iun�rntap�d may..plar,a�s�al��u�ed eypubllrtkcorde. � 1 xM1'S/ I SQ.4T.FLOOR ARG S/SQ.Ff.
Fe 1�E ,Lice '�'rofemlorol t� ` K N�SE RICAL I '
<<�]( OWNER-BUILDER DECLARATION 5T',ECIAL CBICUIT/MLSC
7f-YA Iherebyaffirm that l am exempt from the Contracture License Law for the
Z2_ folumag;reason.(Section 7031.5,Business and Profession.Code:Any elty or
OZ '�TEMP.METER OR POLE INST.
�,� county requlma permit t ocorotvn,alter,Unpmve,demolish,or rcpal. -- _ �
anysuucmreprior to its Issuance,also requlrestheappllcent forsuch permit to roy✓FR DEVICES
O file a signed statement that he Is licensed pursuant to the provlelmu of the _ 1
u,In Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- 11
SOS tiara ofthe Bu.inesslind ProfessimiCods)mthe he Is exempttherefromand L SWNThBNC POOL ELECTRIC 1 VALUATION , �Q
'
applicant base for the alldged
it ag exemption. Any violation of Section inot 7031.5 m re any I I '•.� �' ��
five hundred apears(S jeMtheappllcmttoodull penalty drat nnrethan DU77,ETS$N7TGHF$FIXTUIIES K/- V
g five hundred ddlanhe pr. t
0gz-' ❑I,as owner oftheproperty,d I calm at with wages their sale NEW RESIDENTIAL ELECIR SQ.FT.I STORIES I TYPE CONSTRUCTION
F n
compensation,Bu.1m cloths workgresda sCode:The for or License Law will
q sale(Sec.apply to an ow and f property Code:The or Improves I-Ireme Law
S$ does not apply to an owner of property who Wild,or Improves thereon,and I
who does such work himself orthrough his own emplgm OCC.GROUP RES,UNITS s,provided that such I � 1
Improvements are not Intended oroffered for sale.If,howevep the building or T60—
improvement issold within oneyearofcomplelioo.theowner-WilderwllC. _ 1
t rden of proving that he did'not build or Improve for purpose of sale.). QTY„ �,t -",PLUMBING PERMIT.' `�f FEE 11 FOOD ZONE APN
U1,as owner of the property,am exclusively rontractlng with licensed pp21T ISSUANCE
1
contradon to construct the project(Sec.7094,Business and Profeaslops Code:
The Contractor's License Law does not apply to an owner of property w;. ALTER-DRAIN A VENT-
Wilds or Improves thereon,and who contracts for such ptojeda with a WATER CEA) ro
cgplpdoHiluerself pursuant to the Contractors Licen.e Law. BACK FLOW PROTECT.DEVICE �i ' ' •I FEE-SUMMARY IF LI I am exempt under Sec. B&P C for thh reason r RECTCipr rt rs
DRAINS FLOG ROOF, (SANITARY Y_ N_
Owner ,Dare K AREA,COND.
WORKMAN COMPENSATION DECLARATION RECEIPT p
0
❑I hereby affirm thin I have a certificate of consent m eeU-Inure,or a FIXTURES.PER TRAP I SCHML TAX Y N
certlfiraleo(WOrken'CompensaHOn lruurance ors ceklfiedmpythereof l5ec. E RECLII'TM
• 3800,Lab GAS EA.SYSTEM-]INCA OUTLETS _ � — (PARK FEES Y_ N_
Policy# ' RECEIPT
Pn all CAS EA.SYSTEM-OVER 4(EA) I I BUILDING DIVISION FEES
t hilled copy E hereby fuss a city GREASEANDUSTRL WASTE INTERCEPTOR I PLANCHECK FEE
ertified ropy V f11M with the city Ir,apedlon division. I Air
5 CERTIFICATE OF C.XEMPfTON FROM WORKERS' I GREASE TRAP I (PAID t
COMPENSATION" mm eedift epeR t CE ISEWER-SANITARY-STORM EA.200FT, I !I Date R [ v�
a Rhculm.)n need ratWc�mpleted if the perMtla(oronehundred dollars _ `'b'
(SIBc fete.) I ENERGY FEE Y Nj�
Ice�lythat in the pedorrunce ofthe work for which this permit 1.Issued, (WATER EIFATF72 W/VENT/ELECTR _
dshaB mg employ any perm.In any manner u as to become subject to the WATER SYSTEM/IREATINC
Wmks,ryry Compensation laesof California.Date I PAID
O Z Applic�,t
Z O . NOTICEiO APPLICANT:If,after making this Certlfc o(Exemptlon,you NEW RESIDENTIAL PLMB. SQ.FT. I Date Receipt#
Fshould berme subject to the Worken'Compensalon provleloru o(lhe Lebor TOTA
W Code,youmustlodhwithwmplywith..chpmvbiov orthie perMishall bet
> llcemed revoked. - I BUILDING FFF
a ,CONSTRUCTION LENDING AGENCY I I I SEISMIC FEE
rl here Nrm thatthem Lsammtmctlon lending agencyforth.perform-
� Z a�ceoflh rkforwhlchthIn r ��lI++JJppsuad(Sec.3097,CIV.C.) /��.}� InLECTRIC FEE
a O Leader's�ms � f/.� / PLUMBING FEE r'
LL 1- Lenders 4,11bods, / - (QTY, MECHANICAL PERMIT 1 FEE',• MECHANICALFFE
O ImglfyyhatlhavereacitryryryWWW(((appBrationanddatethattheaboveln for nil 1 -I
O a Iscorrect.l agree to comply with all etyand county ordinances and state laws) `(PERMIT ISSUANCE , PEES PAID: r
} relatingmbpplldingwmtmdion,andh mbyauthor ereprcsentati a o(this
[— (A city to enlertpon the above-menuoned property,for Inspection purposes. ALTERORADDTOMECH.
V — (We)aggppce to Eave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
againsth.b111ties,pdgments,cssaand exponus which may In any wayacc'm" AIR HANDLING UNIT TO 1g0oo CFM) I SUBTOTAL: I
ag.irstaaid City In consequence of the granting of this permit. -&Aian� �' 9h1h AIR HANDLING UNIT(OVER10,CWCFM) I CONSTRUCTION TAX
- Signature of Appurant/Contractor rtail EXHAUST HOOD(W/DUCT) I CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
' Will the applltaht or future building occupant store or haadlchaaardom HEATING UNIT(TO 100,000 BIVI I Date ReeCIDt#
'. material as defined by the Cupertino Municipal Code,Chapter 9.12,.. the
Il❑hYeA Safety Cad 'on 2" a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:No
WdltheapplOanto mbwld32goccupantuseequipmentordevices I
I TI
VENLATION PAN(SINGLE RESID) I ISSUANCE DATE
which eMt havrdous air rontamrnants as defined by the Bay Area Air
R
Qu lity Management Disl ctT (BOILER-COMP DHPOR 100,000 BTU) H°
.• s haveread the d Au.Gamterial.rcquiemenb under Chapter6.95of (BOILER-COMP(OVER 100,000 BTU) p Y
the California I lealth E.Safety Code,St' 25505,25533 and 25534.
understand that lithe building does not currently have a tenant,that tits my, (NEW RES16ENIIAL MECH. SQ FT ` 17•
responsibility to notify the ocrup.at of the requirements which must be rant aa
pri to lssutional! Cc Rcatc toe arty.
a ���,f_�/�(�1
Ownerora thorimd agent - Data� aT� ISSUED BY ✓ -� 1'
a OFFICE COPY