20240 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ii.ildfisa Project Identification PERMITNO.
BuOd Ng Addms: rT_ 20240
ams: one:
J4 k/ -p a CITY OF CUPERTINO6BUILDING DIVISION
Cmtnctor's Name Lk.N. APPLICATION I PERMIT 7
BUILDINGS.SCTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
Arrhltect/Engimsr. Lim No:
Q ELECTRIC PERM IT' , FEE% BUILDING PERMIT-INFO,?'
Address PERMIT ISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapler 9(commmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section7o0Wof Div 9.3ofthe Busttussand ProfeasionaCode,and my
license h to full form and effect. PANELS /(/j
License Clan Lie/ 11
Dale Conaador \\\ 11
ARCHITECTS DECLARATION 201-IODO AMPS 11
ce0 ZO I understand my plana shall be used As public records. JOVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
z d Licensed Professional SIGNSELBCTRICAL �D T7
r<� OWNER-BUILDER DECLARATION SPFGNLC82CUIT/M6C fJ cY
_'�y IherebyaffirnthatTam ezemp[fmmlhe CoNranorsLimns law/fir the
following reason.Setlim 70315,BYanm AM profession,Code:Any tl
H� n'OrcouTEMP.MEM ORPOLE INST.
.� Any le erom rcqubna permRmmmrequires the aprov4demouch permit
< any asutlurttatemetmus Its hat he 13,honed pursuant
attothe (or aucns,of to POWER D��
U floe•arced iOe.Lt that he t Licensed Pursuant to the ti..700(f of the
Con3eithLkemmdPmfmlo9(mmmenthathe h mp"hemfm Divi- SWIMMING IDOL ELECTRIC VALUATION
.. OS aab..isti Buanm and Profmim. Anyvirlatlem heection here(romard /
A 8' the bash fora a rmit su exemption. Any violation o penalty
on 7m IS by any MI6 s nQ
MappB cl ciaPerm M0jecbthe appBcant tore civil penalty ofno morcthan OUTLETSSWITCFIFSFIXTURES a
�.$ Ov hundrMd Of
Pr. NEW RESIDENTIAL VI TR SQFT. STORIES TYPECONSIRUCTION
�n I,u owrar of the property,or my employers with warn u their sole
mpewH¢�,wllldotha work+ndthe atnaurt h rot Intended or offered for
Cle(Set 70K Baalnem and Profmlom Code:The Conradora Ltd.Law
3� don wt apply to u ownerof property who Wild,orimprovn thereon,And OCC.GROUT' RES.UNITS
don such work himself¢through Ms own employees,provided that such
improvements are not intended Oroffertd for safe.If,however,the building or TOTAL: -
improvemenlhsddwtthlnamyurofcompldloNtheowner-bulldervvgI have
tl�urden of proving that he did nm Wild or improve for purpose ofnle.). Q7Y. `: -.>PLUMBING_PERMI .*_' '" .FEE"'- FLOOD ZONE APN
LLj C n owner of the Property,am exclusively trading with IInmM —
mnmad¢s W mntmd e L project Mm 70µBuaNm and Profmfons Code: E&.
The Conntloh L1cer�se law don not apply to u owner of property who .�LIMA& A �)
Wilda or improve them . and who mntntls for such ptpjeds with a . .
dons)licensed pursuantto the Cont etor's License Law. AQC(F7AWT'RO� G"E w r- �,;:4+`':pct '-'.FEE•SUMMARYi '` ;j.,A,•-,),;
I a i ce under Sec B&P C(or this reaun �'.
Owns DRAINS FLOOR R� SANTTARY Y N
Date BBC=#
WOR COh SA ON EC
O I SCIi00l TAX Y N
❑l hereby affbm the I e a certllka f consent en self-Insure,w a RECEBT N
_. •.:f+. cerdfiam.fWorkers CamPe tiro TnurtncemacerttledcapythereefSee.
3800,Lab CJ ` GAS EA ING
$Y57EM1OITILETS PARK FEE Y N
Policy# RECEIPT N
Cam any GAS EA.SYSr M-0VER4(EA) BUILDING DIVISION FEES
CertNM copy h filedheretumlehM. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE 17
Cog(
copy h(Lied�.vlth the city inspection division.
CERTIFICATE OF EXEm PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWMRSANTTARY-STORM EA 2DOFT Date Recei HI
(Im l.bn need not W complaM If the permit h forone hundred dollen
(9100)¢I0 W,A.��.�W,/VENT/EECrR ENERGY FEE Y N
I calcify thatto An Persoan,anyma.¢k..to become
penNjctIssued,
I shad not employ any penin f any manner at n to become subjed to the WATER SYSIFId/TREATING PAID
WOplican Compenndon laws of GOfomla.Date
Z NOTICEl maldng Date Recei NI
. O WTICEco esubjeAM:lf,aherrs'Cothh Certificate o(EzempteLabo NEW RESIDENTIAL PIMB. �'Ff-
Code,shoulbecome sub)M1uthe ply wit'Comp mvislo provhbruofthe Labor TOTAL:
N
Code,you eMgt ked.forthwith comply with such proWlon or this permit shall be O
j deemed rooked. BUILDING FEE
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I henbyafflrm that it..ha construction Lending agency for the perform TOTAL: ELECTRIC FEE
r anmoftheworkforwhichthbi.r tb Wued Sm30Y/,CIv.C.)
O ]enders Name PLUMBING FEE
H larder,Addren Q7Y. .:;MECHANICAL PERMIT FEE MECHANICAL FEB
U 1¢rtffythatl have read thhapplicelionand state rheabove lnformatlon -
W hmroa .lagmtocomplywithaBdtyandcountyodivnosandaatelawa PER.M[T SSUANCE FEES PAID.
yrelating to building construction,and hereby authorize mprcsentatives ofthis
Z citytoenterupon the above-mentioned property fee inspection purposes. ALTER OR ADD TO MECH. Date ReCei tM
(We)agree to save,IndemNfy an d keep harmlm the City of Cupertino
,gains habili udgr=;maundexpeRx .hich.yi.anyw,y..c AIR HANDLfNC UNIT(TO 10.000 CFM) SUBTOTAL: t;
a t id(� oansequen¢ol the sting drhla pemNr. 1141
AIR HANDLING UNIT(OVER 10,ODOCFM) CONSTRUCTION TAX
Slgmwmof App est/Contra rF I EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDO MATERIALSDISSURE
Will theapplicanr or,future uddingoaupantato orhandlehaardous HEATING UNIT(TO 100,000 BM Date listen tic
material a defined by the Cupertino Munldpal Code,Chapter 9.IZ and the
Heahhand Sa(dy CMc Sdtion255324)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: , 0
Yea
❑ No
WBl the appheart or(utum building occupant use equipment Or devices VENTILATION FAN SINGLE RESID) JSSL]0N('F.AATN ITE
which emit hazardous air contaminants as defined by the Bay Area Air �.+ LS/
Quality Management D'u"rid7 BOILER-COMP DHPOR ID0,000 BTU) -
❑Yes MN.
I have read the hazardous materials requirements underChapter 595 of BOILER-OOMP(OVER 100,000 BN)
..- the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building don not corently have a tenant that it is my NEW RESIDENTIAL MECH. SQXT.
rcsporutbtty to edify the occupant of the requirements which moat be rant City of inner{inn
pr1Or ro muahm of a Cedifiote of Ocmpancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY