21888 1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building aultdinc Pm iert Identification 1( /e,_ /- Fc r- `T PERMIT NO21888
1,
-vwrf • APPLA-AIIUNbUBM111AL UA It l
CITY OF CUPERTINO-BUILDING DIVISION
t no-, ar.N me: / �/-kc.No: APPLICATION I PERMIT C l
BUILDING ELECTMCALPLUMBING-M2CFIAMCAL CATEGORY CONTROL
Architect/Engine& k.No:
v� pTY 1 i ,ELE'&RIC PERMIT ', i , „FEE lu BUILDING'4RKMINFO 1 1 .!�^f� _ r ,hi9_..._Ft<C BLDG EL�l
Addre•4 / ' ��ERMIT ISSUANCE -
LI ENSEDCONTRACTOR'S DEC LA RATIO
[hettby af[irmthatlam LLCCnaed under pravtstonso(Chapter9(mmmenc-I APPUANCESRESR)ENTTAL ]B pE�R6'CION
Ingwcittin ellfor0)ofdeffean3 ofthe Busineseand ProtesalonaCode,and my ^ 1 1 \,..ate �`1 w/
license laedion7OW)ofdeffet. PANEIS f-rljL pl, " N
Lkemx,Class Le,V
Date Contntn- r i�1616Ahftls
ARCHITECTS DECLARATION 'OVERtW0 AMPS
- SQ.FLFLOORARFA S/SQ.FT.
pqqp++re O I understand my plans shall be used as public records. I- 'rr p
E I4,� Lkenxd Pmfese1 .1 I SIGNS ELECTRICAL - 0 O O q 7 7
<<�< > OWNER-BUILDER DECLARATION - I SPEO)ALCIRCUIT/MLSC-
I hareb affirm that l am exempt from the Contractor's License Law for the
72 ❑3 following ressan.(Setlon 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
countywhich requires a permit to construct,Ater,Improve,demalbh,ormpair
Sy a.y.,;unurcpdor win,bavance,alnomquiresthe applicant forsuch Permit to POWER DEVICES /
'PJ rc file a signed&atemenl that he is licensed pursuant to the provisions of the
O u,� Contractors License Law(Cfiapter9(commentng with Section 7DM of Diel- SWIMMING IDOL ELECTRIC VALUATION
30 sion3ofthe Business and Profenlona Code)orthathsbexemptthercfromand "� `ui
Gthe bash for the alleged exemption. Any vlolatlon a en tlon 7 at rn by any 3 OUTLETSSWTTCrmsIWrURES !3.30 I• � 0 ( s 3s
00
applicant forapermit aubjectsihe applicant toaovl)penalty 14 rat moreflun
r five Fun rs(SSDD).. NEW RESIDENTIAL ELECTRSQ.FT. STOW'' TYPE CONSTRUCTION
as owner of the property,or my employers with wage a their Bole ,
compensalion,will dothe work,andthestroture U not Intended or offered for
q .1.(Sec.7044,Buelnessend Pnoesocus Code:The Contractor.License Law
does not apply to an owner of property who Wild.or Improve&thereon.and OCC.GROUP RES.UNHS
p3^ wfiodonsuchwork hlmseB orthrarghfileownemptoyen,provided that such
improvements are not Intended aroffered torsale.if,however,the building or ., TOTAL:
improver ntlssoldwithlnoneyearo fcompletion,theowner. uilderwill:.
17Ie�arden of paceng that be did not build or improve for purpose of sale). QN.� ^ `11 ,PLUMBINGP,ERINIT" t, 'FEE' FTOODZONE APN
LJ L
as owner of the property,am exclusively contrfrIng with licensed PERMIT ISSUANCE I
contractors to oxnatruR the project(See 7644,Busies&.and Itcaions Code: /
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER IRA)
-+ Wilde or Improves thereon,and who contracts for such P(afet.with a FEE SUMMARY J
aQdt�amr(.)Bcensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE
l am exempLunder Sec. B &P C for this..a /TU'�51Ij1'i'I'n5 7
DRAINS FLOOR,ROOF,AREA,COND. SANITARY
Y N
Ow r RECED'T x
K �rlrN T10 ^ I FUTURES PER TRAP / op SCHOOL TAX Y N
. hat I Fave a ib, of consent to.l 1-Inrura.or.a D RECEPT M
crmficA..fWorkers Compensation Insurance are certifled copy thereof(Sec. GAS G.5Y5TEM-11NC.40UTLE'IS �PARKCFP. Y N
Policy = l INGPIV
aY I GAS EA.SYSTEM-0VFR4(EA) BUM ) INC pl VT510N FECS I
COG.-OG.-fiedcopy U hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI'IEC FEE
0Certifled copy Is filed with the city Inspection division, - I - -
CERTIFICATE Of INETMP"HON PROM WORKERS' , GREASE TRAP PAID
COMPENSATION INSURANCE 26
(This action need not be completed if the permit is for one bond red dollars SEWER-SANITARY-STORM EA.200FI. Date RCCCIIItiI
($1fD>or less) ENERGY FEE Y, N_
I cartify that In the performance afthe work forwhlch this permit is issued 7 WATRRHFATERW/VENT/ELECTR 'QQ FEE p
- I shall not employ any person In any manner so u m become subject to the WATFRSYSTEM/TRLATINC PAID `'(,
Workers Campen.gion L.w.of CabbmrAa.Date
ZZ Applicant NEW RESIDENTIAL PLMB. SQn.
p NODCETO APPLICANT.If,after making this Certlflale of Exemption,you 1 — 1Z.
N should become.ubjecttothe Workers Comperoaten,prevblons of the Labor `T p1 rT .1r 1 rg TOTAL,
� ; Code,you most forthwith comply with such provisions orthis perno.hall bet Ct's l47\L � W i`` I" JBUILDING FEE
LU deemed revoked. 4 I I SEISMIC FEE l
CONSTRUCTION LENDING AGiSICY
d IhercbyxM.that there b a construction lending agency for the per form- TOTAL: O ELECTRIC FEE Z.
7 Z ance of the work for which this permit is bsued(Sac.3097,CIv.C.) , . I
02 Lendara Namr: ' t � PLUMBINGFEE
LL F Lenders Address QTY. MECHANICAL: PERMIT'' .. EiJMECHANICAL FEE
U I certifythat l have readthisappiicationand gate thattheabove In formation
O W bcorrvt,(agmatocomply wfthallchy.ad county ordb,Ar.and gate law. PERMIT ISSUANCE ` �Z,OO FEES PAID: Ca�'`
CL relating to building colutructlon,and hereby authorize representatives ofthlf F\ �Qb r
F N city to enterupon the abov>mentioned property for Inspection Purposes. ALTER OR ADD Date RecefPlp
V ? (We)agree to nve,bobser (fy an d keep harmless the City of Cupertino AMR HANDLING UNIT((010,000 CFT7 ' �-M
.gal Iltfr.,judgments,"sand expenses which mayl wtyfasenq SUBTOTAL:
is City In consequence of the granting o 0.
� AIR HANDLING UNIT(OVER 10,000CFM CONSTRUCTION TAX
a p".Of Co t,ttet note EYHAUSr HOOD(W/DIiC'D CO�NSTRU ILTAX PAID:
HAZARDOUSMATVMALSDISCLOS `— 0�
Will theappllont or future building omrpant store ndle hazardous I,/ HEATING UNT(TO 100,M)BTU) , /�/ Oct Date Rece1D
materulasdeBrudbythe Cupertino Municipal Cod a Chapmr9.12,and the IF BEATING UMT(OVER 106,600 B rM
_ IIr.bhand S4etyCodr Se t1on 25532(.)1 TO
Yes -
Willthnappllontorfuturcbulldingoruit.muse equipment or devices , VEMILATION PAN(SINGLE RFSID) SD ��� 1$CSJJANCEDATE_,
which emit havrd....I,contaminates.,defined by the Bay Area Air C'�� `�,,a�� ' ( 2Si �'•)
Quality Mawgemcnt Distnct7 BOILER-COMP OFD'DR]OO,IXD BTU) GW �C,4 E�yrybiTlp,Mp� �'a (i
� 1 Yca n1�1 No uR �e+g.✓a
•,; 4have read tfie hazaidou.maicrlab rcqulremenb under Chapter 6.95 of BOR.ER-COMP(OVBl1C6,OW BTU)
the CahfornU Haalth&Safety Code,Sectloru 25505,21533 a ad 25534.1 SQ.FT 'Jul.1 & p
understand that❑the building does not currently have a tenant,that it t my' NEW RESIDENTIAL MECH.
rspondbllityto notify theoccupant of the requirements which most I met -
priortolssuanceofaCertrbcateofOmp snry.
(Tuner or authoriawd agent Date al Cy)TOTAL: IISSUEDBY:Nt.
a
OFFICE COPY