21059 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
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42 3%TY OF CUPERTINO-BUILDINGDIVISION
ono: N LIf���QqAPPLICATION I PERMIT V
1A DJNO BUrLDING-ELECnUCAUPLUMBIN�MF NICAL CATEGORY
Architact/Englaer, Lk.No: G G
'7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 3 '-�+ / I'FRMBTISSUhNCE �,� PEOMIT
YD-C� .
LICENSE ONTRACFOR'S DECLARATION 9 19q 1:1
I hereby affirm that l annIftsistard under provisions of Chapter 9(commeno- MPLIANCESRESIDENTIM, ]OB DFSCRB'1'ION
Ingwlth Section 7000)0fD1vin1oa3 afthe Busleass dPmkalonsCode,and my t
I icense I. fou and effect /� PANELS (A/_�I �/(
Llan Baas CmA o 7 Sy� v� �o -7-
a
`
Date Contradoe /CJ
ARCHITECTS DECLARATION 201-1000 AMPS
q�u aO z I understand my plans shall he used a public records. OVER 1000 AMPS SQ.FT.FLOOR AREA ��
E U t, Licensed Professional SIGNS ELD TRICAL D
�Q63 OWNER-HOLDER DECLARATION $[+ECIALCIRCNT/ �a s
2 ,�4 1herebyafl.'hat]am exemptfamthe Contractor's License Law for the
qqqqqq following recon.(SeW..70'71.5,Bu.i..and Professions Code:My dtyor
f @ countywhidmqumaper trommtmct,alter,lmptove,demolbh,ormpair TEMP.METER OR POLE INS['.
W8`'� a anystm=mpdortoibbsuance,al mquim.theapplkantfor.uchpermitto Pan F O U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES ['(�(.�„71;.1
Q6 Contractors Lle.—Ls-(ClupterI(m—.-gwith SMion7000)ofDIW-
�OS don3afthe Butln =dPmfembtuCWd )orthaheisemm therefmmand SWBdMNGPOOL F].ECTW `T eInALUpTION
d
the basis for the alleged exemption. Any violation of Section 7031.5 by any ..y N ,qt 4 .tltc7 {t,/ :?-pv0
V/
p applicant for a person subjects.m
sthe applicant to a dWl penalty of net than � OUTLETSSWITCH[SFlXTUR Sl ya f`�/ lr
five hundreddollarsof the
NEW RESIDENTIAL ELECTR ` 7 (, TYPE CONSTRUCTION
��n ❑Las owner of the property,or my employees with wages a their mk 1 � NOR compensation,(Sec.70K B..terl do heworkendthes menve is Code;The nn Contedcs Licame,Lar t"S1�t rasj�{.IL's,.
O sale(Sec.7046,Bwlnessad Pro(emloa Code:The Contradots Lireae law
$ does not apply man ownerd property who Wilds orimpervesthereon,and V OCC.GROUI' RES.UNITS
who doessuchworkhim df orthrough hiaoweemployees,providecithat such
Improvements are not intended oroffered for wk.If,however,the Wilding or
Improvemetrtb.dd withinoneyearofcomplation,the owner-builderwill have
t .dan of proving that ho dm net build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
FLOOD TONE MN
Lj Las..or in the property,am exclusively mntrading with dC.de, PERMITISSUANCE O
The Contractor's
coawdthe project(Sec.appy to
of pro ow Code: 6
The Contrador'e Llceae law does fiat apply tct an owner of property who
Wilde ar Imprensa thereon,and who ractaas (m such p(ojecb with • ALTER-DRAM b:VFM-WATER(FA)
cgp[fado(.) empt pursuant totheContradw'.Lkenm Law. FEE SUMMARY
I am exempt under Sec. 0 by P C for fhb reason BACK FLOW PROTECT.DEVICE
OUTSI UP FEES
ORAINS-FLOOR,ROOF,AREA,GOND. SANITARY Y N
Avner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to aelf-Insure,or a FD(TURES PER TRAP SCHOOL TAX Y_ N_
RECEIPT M
c,m Vn of Workers�'�Compensation Insurance man {.d{�o�Pythe—((Sec. l GAS EA.SYSTEM-I NCA OUTLETS Z. PARK FEE Y_ N
Policyp S Tom''f _I' - ■a ' GAS FA.SVSITirt-OVER6(FA7 RECEBRM
Com BUILDING DI VISION FEES
[Cert] ed ropy b hembytumGREASE/NDUSTRL WASIE INTERCEPTOR PLANCHECK FEE
�RLrrtlBed ropy b flied with theecity
ty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID —a—t0 714'
COMPENSATION INSURANCE SEWEF SAMTARY-STORM EA 200FT Date Recei tN
(This section need not M completed lithe permit b for one hundred dollars
($100)ar leas.) WATER HEATER w/vErrr/n.EGTR ENERGYFEE Y N
I cema
rtifythat In the performance of the work forwhich this permit is issued,
I ebull not employ any Person In any manner so as to become subject to the WA7FIi SYSTQd/TREATING
Workers Compensation Lawsd California.Dare PAID ii VV
Q Z NOTICEt NEW RESIDENTIAL PLMB. SQFI'. Date Recel t#
Z 0 NOTICEtt)MPIIGt to
after rs'Co fhb Coon pro is Exemption,you
M N sode,yoood =aame forth it the Workers'Compeaasons orthbaafthe Laborbe ` 1' , ts�.s�,1 C T
� deemed
=at forthwith amply with each provisions orthb pertdt shall be \ `^erf^� il'oKM"MK/ G FEE
VU
IL > dcerrmd revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
(herebyafgrmthat there bacoatadlonk(Ser.3genryfor C.) perform- TOTAL: ELECTRIC FEE
V Z Lenderthe work(orwhkhthjs gpr las ls�med(Sec.3W7,CIv.C.) W
0 Lender's Name ��4 /`-'� PLUMBING FEELL GY
1— Lends/.Address QTY1 MECHANICAL PERMIT FEE
O W Inertlfylhatl have readthis appllcationand date thattheabove information MECHANICAL FEE (�
4 lacormet.I agree to comply with all city and county otdlnanoaand data laws l PERMIT ISSUANCE t'2a,CV FEES PAID:
>- N relating to building construction,and hereby authorlu representatives of thin
F Z city to enter upon the above-mrentloned property for Inspection purposes, ALTERORADDTOMECH. 1� Date ReceiptM
z (We)agree to save,Indemnify an d keep harmless the City of Cu pedino
a mut abilities,pdgment,c d expenses which may in any way aceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
I Id City In con of the granting of Chia u.
�2e-90 AIRHANDWNCUNIT(OVER IO,000CFM) CONSTRUCTION TAX
Tiig�muture of App an ontrador Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bu llding occupant store or hand le hazardous HEATING UNIT 100,0008TU) _I L Ivat Recei tie
material as deft nod by the Cupertino Municipal Code,Chapter 9.1 2,and the HEATING UNIT(OVER 100,000 BTU)
Hely Cede Section 25532(a)7
Fl Yen
ealth and SafNo
Willthe applicant Pture building ocmpantuse equipment m devices VENTILATION FAN(SINGLE RFSID) ILIO ISS'
which Cant haaardous air contaminants an defined by the Bay Area Air /If
a Quality Management District? BORER-COMP 0HP OR 100,0(U BTU) 9
ya.
No
(have read the hazartlous materials requirementsunder Chapler6.95 of BOILER-COMP(OVER 100,000 BTU)
the California l lealth fa Safety Code,Sect low 25505,25533 and 25534.I
uderatafid that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr. xx
mor to IssaLo of a Certifcupa icate
ccupanequkementawMcF must be mat
resporolasuanee daytheaxteof Ocmof he req
Owner or authonred agent Data TOTAL: ISSUED BY:
�s
f OFFICE COPY