20070APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY.
-
Building Project Identification -
Building Address:
2-3-5-66 I ,o ke Di -20070
PIiRMITNO.
mer. are:me:
2r 1"V1NL fG
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION /PERMIT
BUIL.DIN FU3CTRICALPLUMBINCMFLHANICAL
emtrannra N.me:.Na:
Ko C�
cA RY
coNTROL.
A rchBect/Engineer. No
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add. 0 M IS (D 1A 1 S.
�. O El El
PERMITI5SUANCE
CONTRACTORS DECLARATION
T hereby affirm that l am licensed under provisions of Cha pter9(mmmme
Ingwth Sectbn70W)ofDW m3ofthe Businasand Profen Code.andrrvyA�-
license is to full tors and eflers.
WconseClam LIG/
APPUANCESRFSmENTIAL
I�A,s DLSCRIm1C1N
G • ry •' l e �( —S I ` e
]
CL
PANELS
Date GHITECr
ARCHITECT'S DECLIRATTON M
]uederslanyptro shall be used as public records
Liman] Professional
OWNER -BUILDER DECLARATION
IherebyafRrenthat L ameaempt fmmthe Contractor:Ltnrue Lawfor ma
folbwing myon. 6ni1m 7ffl15, Basins and Pfese
robm Code Any dtyor
cwntywhkh requbvapem0t tommtroct,attr,improve, dermlhh,or rtpalr
anyummmpr totbL ame,abo.equreesmeappBantfasuchpem w
file a signed statement that he b Bcersed purreant to the pswisdom of the
ContrMorb License Law lC per 9 (mmmendng with Sect 7008) of Divi.
3 of the Bustnesaod Profewbm Code) or that he b exempt therefrom and
the bub for the alleged exemption. Any violation of Section 7MI5 by any
applicant for a permit subject the applkam to a civil percRy, d not mom than
five hundred
owner ofthepro
r s owner wflkith property, or myemployeesb with wages r their sole
cls i5e,. 70Kdu� Business work, andtheatmctumbnotntended oroffered(or
sok not 7064, Boal, and Ihofubrc Cade: The Contractors Llrrme Law
don not apply roan owner or property who builds empI r improv tkrtan, and
who donach work t int eBmmrough his own e . If, h., provided that such
Improvementamrot Intended orro(corfaseak.ISha r-,Werwth,building orhave
Improvementbsold vdthmarcyearofcompldbn,theowrcr-bullderwW have
th� rdenof Proving that be did not bund or improve for purpose ofaak.).
I)a4 as owner of the property, am i,clu dvely cvntncnng — bmvsed
mm traciom to construct the project(Sm 7044, Bwbean and Professions Code:
The Condmctur• Lien Lew does not apply to an owner of Property who
builds or Improves thereon, and who cermtes for such projects with a
ytlt(ctor(a) Bmneed pursuant to the Contractors License Law.
LJ 1 a aempt seder Sac B k P C for this reaan
,} 1
Own I �I'><. �i e "'I t 3—
woRIQ.LAN cohf, g sAT1O ¢J� RATION
❑I hereby affirm thx I have • mni/iot t'6dsent to .eB-Insure, or •
mnBlcateofWorkem'C«npenaatlonlos =re maunifiedropythereof(Sec.
3800,Lb C.)
00
OVER
OVER 1000 AMPS
SQ. Fr. FLOOR AREA S/SQ.
ED IN
U E R
VALUA N
SIGNSE MCIRICAL
5[aE{IALC6KIIIT/MLSC
-
TEMP. METER OR POLE INST.
POWER DEVICES
gIVBmL\9NG POOL ELECTRICnlon
OULI.EISSWITO}ffSplXlvgS'DXrE
NEWRESIDENTIALELECIR SQFT
STORES
TYPECONSIRUCTION
TOTAL
QTY. PLUMBING PERMIT FEE
OCC. GROAT'
RS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN AVENT- WATER (EA) '
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
,
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y_ N
RECEIPT If
FIXil1RES PER TRAP
SCIdOO1, TAX Y N
RECEIPT
I GAS PA. SYSIT]d-1 INCA OUTLETS -
PARK FEE Y_ N
GAS FA. 9YSTEM-OVER4(EA) _
Cam ny
B U ILDING D I VISI ON FEES
CCenlBed ropy b hereby fuminhea.
❑ CcrtBled copy b f lint Mth the city lmpecUon dlvisbn.
'CERTIFICATEOFEXOAPTION FROM WORKERS'
COMPENSATION INSURANCE
T9)crless.) neM rid bcormpleted Rthe pemdt b(e care hundred dollar
(5100)olea.)
Icshallnot employ anyperson ria Mme work for tobecospemdtblto the
Woken'Cnaallon Veviof GlyBamt�eDate L to berme subjaa to the
ApplicanNOTICE
eREAS'E/BJDUSIAL WASTEINLIRCFP'IOR
PLA CHECK FEE
PAID
ate Reeui t#
GREASE TRAP
SEW FR SANITARY SCOILM FA 200FT.
WATER HEATER W/VENT/E1.ECIR
ENERGY Y N —
PAID
Date R IN
WA.IEtSYSIDH/TREATING
NENVRESIDFNTIALPLMB. SQFT.
NOTICEco e,su.ICAM:ll, soler rrcbngthisper Certificate of Eaemptbrvyou
Cc,de,shoulyou forth it the Wanken' CompewUot. or this
Code, you mut forthwith mmpty with such proal by orthb permit "I fin
permitns of Labbe
deemed rooked.
CONSTRUCTION LU40MG AGENCY
I hereby of lrenthat them 13. corotmctlon lerding agency for the perfom,
ance of the work for which this pemdt b teed (sec 3097, CN. C.)
Tender. Nittre
Lenders Address
1 onUlythat I have mad thbappllolbn and statethe the.;.; e
heabove lnfomutlm
b mrrect.Isgree to Comply wdh.B etyard county ordinances and Wte laws
relating to bulldog coos motion, and hereby autholre mpresenttives of thin
cry to enter upon the abovtmentbned property for tropectbn purposes.
(We) agree to save, LdemNfy an d keep harmh s the City of Cupertino
ago Wt Bab WUes,Judgments,aoRaami expenses whlch may lninywayamue
w
agat said city In consequence of the grarrWWnn5 of dbl. permit
/ yu _ / OSI/��.Iy6
T AL
BUILDING FEE
SEISMIC FEE y
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FE
MECHANI FEE
PERMIT ISSUANCE -
FEES PAID:
ALTERORADDIOMELK '
Date RL'CCI it
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTA
AIR HANDLING UNIT (OVER 10," CFM)
CONSUCTIONTAX
Signatureof AAsppBuninth ito.Iu.. (// Date
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or hanare
dle hrdnrue
material as de0ned by the Cupenbo Municipal Code, Chapter 9.17, and the
Health and Safety Cod, Salon 25532(.)?
TT�� Yn No
�a'Rlthe. ppllarder arebullding occupant use extulpmeN ordeviccs
which emit harandot, air mntamW Me as deflrcd by the Bay Area Are
Quality Management District? -
Yet No
Ihavclead the havrdouematerials rcqulrementunder Chapter 6.95o(
the Cebtomle, Health k Safety Code, Sections 75505, 75573 and 75534. 1
uMemtand that if the building does not currently have a tenant, that it b try
responlbBlty to notify the occupant of the requirements which must be met
prior to tesuancu ofa Ccrtllkate of Oacupanry.
Ext-uusT Hoop M'/Dien .,'
OT
CON RUCTION TAX PAI
HEATING UNIT CTO 100.000 BT)
te RCCCI IN
HEATING UNIT (OVER 1011,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
l77
_ APR v
f R
"V '
'
��h7 c� Cfm,>rfmn
ISSUED BY:�j_�_��k-j%LC..� .
BOMER-COMPOHPOR100,00DBTU),
BO LER COMPOVFRIN,000B n
NEW RESIDENTIAL ME0 SQFI'.
Owner or authoal,ed agent Date
TOTAL
OFFICE COPY