19955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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pE 6 19955
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p CITY OF CUPERTINO-BUILDING DIVISION
• Cpmntt�aN-m: �•s-�. IAe.Na APPLICATION I PERMIT
V 6Tr-s 6 BU[IAINO-ELECIRICALPLI BINGMECHAN[CAL GTIX',ORY CONTROLIf
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A1dms&0q_ H PERRATISSUANCE ��yy,�
LICENSED CONTRACTORS DECLARATION Yil 1:1 El
[hereby affirmthat l amlkmsed under pmvWmuof Chaptrr9(ccerm,me. APPUANCFSRMDEMIAL JOB D6C
Ingwlth Se n70f1D)of Di Wm3ofthe Bustnesand Pmfa maCodgand
flout bIRfullforteanddfe PANELS
Llate k.Y
Clams LLEX
I Date Cie.#
ARCHITECTS DECLARATION 201-10)0 '
�7. Itarderstand Ry Fla.shall b,used as pubbe moods. OVERI"AMP5 SQ.17.FLOOR AREA S/SQ.FT.
�j Llansed Pmfmabnel SIGNS ELECTRK'.1L
6 OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/ML9C
zF' � Iherebyaffirm that lam ezempt from the Comradoh License Law fee the
following reason. Seet].7m 15,Bu.br s and Pmfesbn.Code:Any eity or
O t:� TTW.METERORPOLEINST.
K� countywhich requBesapemJttomvtrud,pter,lmprove,demoWh,arrepatr
anygmu mprketolbb me,alsorequbestheappBesntfauchper to POWER DEVICES
5 file a signed statement that k is licensed pursuant m the prervblon of the
�a Contntlor's License Law(Chapmr9(mmmenCng with Seabn 700J)of Dlvl- SWE.O.UNG[VOL ELECTRICO Mon3ofthe Bs
ustneand Pmfessbrm Code)orthat hebemmpttherelmmaM VALUATION
the basis for the alleged e.ernptton. Any Ac atbn of Section
711115 by any Q
O� aPph.t for.permit subjecuthe.pplkant to.dvil penalty of not morethan FI ;x3S Qo
five hundred dollars(T`5(hT). S J I
�n ❑I,as owner of the property,or my employees with wages u then solo STORIES TYPE CONSTRDLTION'
CC mmponsation,will d o the week and the structure b ont Intended or offered for
5� ���
s66er.70K Busbies and Pmfeuloos Code:The Contractor.!Lame law
$ does out apply to an owner of property who bu lid.or lmprwes thereon,and OCG GROUP RFS.UNTiS
whodoueuchwork himseff orthrmgh hlaownemployees,provided thatuch
Improvemema are not Intended proffered for sale.If,however,thebulldNg or ^
Impmvamem lesold wdhinereyearofcompletlon,the owner-bull lerwlli have "
ttrden of proving lhatkdW not buiw
ld or improve purpose of sob.). QTY. PLUMBING PERMIT .FEE
yJ I,art owner of the promtrm
property,am mIuahely naning with Ilued ROOD ZONE APN
ecoto rturuct the project(Sec.7044,Bualnesaard I'mfesloro Code: PERMIT ISSUANCEThe Contndore LI¢�rLaw does not apply to an owner d property who
lou Id. or Improve thceon,and who mntram fee such pipjecb with a ALTER-DRAW 4 VENT-WATER MAI
cq=E o,W Barued purmaant to the Contndar.License law. BACK PIDWPIIOTECT.DEVICE FEE SUMMARY -
L�1 .m e.emp unders�r_.�s /IJ'a P C for thiss2{aunnOUTSIDE FEES
�1— J,s— DRAINS IT.00R ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION /[s{�,—^��ON REIPT#
111 hereby affirm that I have a certificate o m'irAt to satf-ben,or ARES PER `A100L TAX ECY N
mAffioleofWorken'Compernatiaw Nunn.maaHgB mpythenofpec. RECEIPT
3800,UbC) CAS FA SYSTEM-1 INCA OUTLETS PARKFEE - Y_ N_ -
RECE
I GAS EA.S=EN1-DYER 4 MA) DING DI Y
CoCit ray BUILDING DIVISION FEES
CMytfted copy is hereby furnished. GREASE/WOUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertNM ropy b filed with the dty,Inspection dlWstmi.
CERTIFIGTE OF E(E]NPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWFR.yAMT.ARY-STOR.M EA.lm•T Date Recei t#
(IhorI..) need fiat be completed lithe permit bfa aria hundred dollars
(g100)rtifytJ WATER NEATER W/VENT/EL.ECTR ENERGYFEE Y . N
Icertifythatlntk pedomuna of thework forwNdttNe peeNtbbued,
I.haB one employ any penin in any.,,so as to become stabled to the WATER S151PA1/TR
Workers'Campewtlon law.of Califomb.Date EATING PAID
PP NEW RESIDENTIAL PLMB. SQ.Fr.
Z NOT[ETOAPPLICANT:ILaffermJdogthisCartffhm.fEzempto ,you Date Recel t#
P y shoWd become abFct to the Works'Compevatbn provbloes of the labor TOTAL:
CC _ Code,you crust forthwith comply with such nowbors ortlda perudt Jullbe
W > deemed reeked. - BUILDING FTE
W
—p CONSTRUCTION LENDING AGENCY SEISMIC FEE (�
I hereby.ffinn that there b a mrutrudiw krding agency for the pedortn
(� O ia,d.rew`)`forwl hthbpermnbla ELECTRIC FEC
U (Eee.3097,Cw.C.) TOTAL_ ELECTRIC EEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Inrti(ythall have mod lhbapp0ratlonand Mate thrtthe above lnforrtutlon
Is mrreat.l agree to comply with all efty and mtanty ordinances and Mate lawn PERMIT ISSUANCE FEES PAID:
} N relating tobuilding mrotrudion,and hereby authodre reprcaenntNn ofthb -
F Z dty to enteruponthe abwo-mentbned property fa WpMlon purpo� ALTER OR ADD TO lvfl) . Date Recei [#
(We,.gree to save,irdamnify an d keep harmless the City of Cupertino SUBTOTAL[
V against habWtke,Jadgmenla,costs and expenses which may In any way acvue AIR IiANDENG UNIT H000 O 10, CFM)
agalnl xld City in renseue.of the m of thin pe
�,y� / /A VQ
/L7G MR HANDLING UNIT(OVER 1a,"CFln CONSTRUCTIONTAX
Slgnaure pl AppOnnt/2Eslssrar ate . EYHAUST HOOD(W/DLC.T) CONSTRUCTION TAX PAID:
.HAZARDOUS MATERIALS DISCLOSURE
Will theapPLnmorfutun bulldtng ccapart pore or hardk havrdous HEATING UNIT(M 100,000 BTU) Date Recd t#
moterbl art deRrud by the Cupertino MueIdpal Cade,Chapter 9J Z and the
Heahh and Safety Cade Section 75532(a)7 HEATING UNIT(OVER IOLOOD B'T(q TOTAL:
❑Yes No
WBlthe applhntor tun bullaing omnpantuse equipment mdevtm VENTILATION FAN ISWGIE RTSID) - ISSUANCE DATE
hkh rout hanndoue ale enntamlvms as defined by the Bay Area Me
lity Nt utagemem Dierld7 BOILER-COW QHP OR 100,000 BTU)
i !�
Y Yn have read the h ❑No
avardoun materials,requirements under Chapter 6.95 of BOILER-COW Iffy"3111).
the California Health k Safety Code,Sedlom 75505,75533 and 75534.1
urderata ed that if Nebuildtngdoet net currently have atenant,thatlt bmy NEW RESIDENTIAL MECH—SQJ,7 '
respor 1flyto notifythecceapamofthe requirementswhldi novobe met
prior to Lsuanee ofaCertifbte ofOavpanry. CIIy of rs
Owner or amhodnd agent Date OTA L: [SUED BY
OFFICE COPY
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