21487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ee Ideatiflaton1'IXA9TNO.
Bu/Obcss: e I? 2.1487
ams: one:
CITY OF CUPERTINO-BUILDING DIVISION
Cont r'aName: LIc.No: APPLICATION /PERMIT V v u F!
Z BURDINGELDCr ICA4PLUMBINC MECHANN:AI, CA'IKARY CONTROL Y
r<hhea/Engircer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PFRMIn$UANCE
I lrneby affirm that Ian,lkcrued under prwWaa of Chaper9(commemc APPLIANCES-RESIDENTIAL It SCRIIrT10N
Ingwlth5ectbn7OW)of Ml m3otthegualneeeand PmfotlmsC e,.ndrrty _
limnse b f�9j�.na effect.2925 S_$` PA"Els &4>r% L— QF-
CHITECrS DECLARATION 201-1
aO Zp I undertlerd my plans shall be used aa public nada OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CC
U Lfmneed professional r SIGNS ELECTRICAL
�< OWNER-BUILDER DECIARATION
t„ Ihercby a(Brm th.tlam eaemptlromthe GOMnaars Llmnse Liv fa the SPECIAECIRCUIT/MISC
6�F f ntywhrt Te .f$ gpermi5,Bualnuat ,rope , e=Hshnw'mpor TEMP.ME1FR ORIOLEWST.
muntywhkh mryWapermtmcorutruct,.Icer,lmprove,derroWM1;artp.lr r ^
any a signurt pM tolbhe heisako requbes that the lasuch Pn'to T 7 est
(Ile a tlgncd taement that h<b 11¢nsed pursuant to the proNelom elthe �~POWER DEVILS t at
Conl.orb Lke.Ul (Capter9(mm nMgwlth Sealon7DD0)of Divi-�� Vd'
SOSELECPRIC
SW
slon3of the Buelnme and Profembro Code)ortEtl hebeumptthemfmmandSWIMMINGNC IOOI, VALUATION
the basis for the alleged exemption. Any vIolWbn of Nation 70115 by any, OI17LE,ISSW(.ICHES}TX1.lJRES�
<5 aPpliart fora permrt sub)ectsthcappllcant to.cfwll penalty dna nnrt`.Fan
t ❑vc wndrtd ddhrs("5043). n n _SOFA, STORIES TYPE CONS[RUCTION
❑I,as owner ofthe Property,or my rmpbyeee with wagesaztheir Bole t`TW R®DFNf]'Vl
t.]a mmpenaadon,wBldothe wakand W<atmrnrehrotlnterded or of(ertd for
G ❑ sale(Sec.7034,BuaLiwmul I'mfeabv Code:7he CoMranoh Lianas Taw
doesnaapplytoanw afpmpertywhowiwsorlmpmvesth r,and
wh.odwsurh work hBrvellathmngh M1laownemplayees,pmvdedthatuch OCGGROUP R6.UNITS
JmPruvemerda arc not intended m,iffered for It.It,however,thewilding or TOTAL:
Improvement bald whhinmeyearofcompietbn,the ownerbullderwlll have
tkalzurden of proving that M did not wild or improve for pur,oac of ule.L QTY. PLUMBING PERMIT FEE FIDOD ZONE APN
1,as owner of the property,am exciuelvehy cortracting with licensed
contract.to construct the project IS,7044,Bush®and Professions Cade PERMIT L%UANCE a1
The Contractor's Llaanotre LAW does napply to.n owner of property who ALTER-DRAW 4 VENT-WATER T_-04
bum.or Improves thereon, and who contracts!a such pct
(ojea with a
cW1r+ctor(s)Bcenacd pursuant to the Contractor'.Lae.LJw. BACK FLAW PROTECT.DEVICE FEE SUMMARY
[_f 1 am exempt under Sec B 4 P C for this reason
OwnerDae DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N—
rt a• RECEIF T o _
WORID.the COMPEN5AT10N DECLARATION FDOLTRpg PER TRAP SCHOOL"TAA Y N
❑1 hereby affirm that I have•arti/bte d conxnt to s Ehe RECEIPT,L
mti0ae ofWorkcn CompensdlmlrwrranaaaartBkd ropy Nernst(Sec. GAS FA.SYSTEM-11NC.4 OUTLETS s� PARKFEP Y N
3800,Tab CJ
Cook-'R CAS EA.SYSTEM-0VER4(FA) RECIE
Y BUILDING DIVISION FEES
CertBled copy b hereby furrdahed.
CtaNed copy is filed with the city inspection dtvleim. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE. TRAP PAID
COMPENSATIONINSURANCESETVER-SAMI'ARY STORM EA 2(gFT Date Rcoel t#
Rhb need sectionnor w carriplcted Rtb permbit faons hundred duties
MW)ahese.) WATFRHEATFAW/VENT/ELECTR ENERGYFEE Y N
I mrtify,that In the perforrnsna of the work forwhlch this permh b imued, —
I shall not employ any pe.In any manner o u to become subject to the WATER SYSTEM/TREATING
Waken'Comperoatbn Laws of California.Date PAID
O Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQFF. Date Ret:ei t# -
Z O
NOTICE TO APPWGNT:ll,afterrnsking this CertRlate of EaemptlDn,you
HN Nmld become subject rothe Worken'Campenutbn prvvlsbnso the L.wr TOTAL:
Code,you at forthwith comply with such prowlons orthb permit shall be
> deemed rewked BUILDING
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I Hereby a(Erm that there b a construction lending agency forthe perform (y ELECTRIC FEE
Z Lend". Name for whkh this permit b Wood 15ee 30Y/,CIv.C.) TOTAL: I�`M
LL O Lend"..
PLUMBING FEE Cd
LL H rcndera,Yadrta. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iarttfy Natl have read Nbrad state Nd
appllatlan. atheabwe Nlormwim
S bmrnt.Iagreeto complywXhWtltyabye,tb ordl,pnmand tlale laws PFRh1R ISSUANCE FEES PAID:
reloting towlldNg mnstroalm,and heeby authorize rtpreacnbtiva o(thb
Z dtyto enterupon theawve-rmentlnred property for Inspection purpose". ALTERORADDTOMECH.
(we)agree to sane,Indemnify an d keep h,mrdeas the Chy of Cupertino Date Recei t#
V .gaWtW les,judgmenb,aebard expenses whldi may Nanytvayacwe AIR HANDLING UNIT CFO I0,000CFM) SUBTOTAL:
against �equ
d insenaof egrantingdthb permit.
AIRILANDLINGUNIT(OVERIB00CIM) CONSTRUC170N TAX
st o t ao ATERIALS DISCLOSU 0.E
^Date
D&LASHOOD(W/DLICT) CONSCRUCTIO TAX PAt#ID
:
RHEATING UNIT 90 I0,"871Will the. u
noerialas defined by uorft
inoMuNdpeCod,Ch.pter93;andthe Date
1h,.11thard Safety Code Secum2S532(a)7 HEATING UNIT(OVER100,000BM f r J OTAL:
TV 11
Yes No v. .
Bltheappliam arfutum wOdingocanpantuneequipment adevlccs VENTILATION FAN(SINGLE RESID) ISSUANC ,ATE
which emit la.M.eir comam
minaa.s deRnsd by t Bay Area AU 4)MTs
Qua thy Mara gement District" BOILER-OMP OHP OR 100,IXD BTU) (.aNl rt 01-ra"�
® Yeen eo 2N:
have radtheh rw materials requiremanb under Chapter 695 of BOIL_R-COMP(OVER IMODO BTU)
the Caldomia Health 4 Safety Code,Sabre 255435,25513 and 25534. I
urd"aw that if the wilding dos not currently have.tenant,that It is my NEW RIDDEN71AL MEC". SQFT
rmpommBltytonaifythe.Nmdthertquire Mawhlehm mbemet
prior to W..nm d.Certtf caw of oavp.nry. .
Owner a authorlad agent Dote TOTAL ISSUED BY:
OFFICE COPY