21087 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build].,PioJed PERMIT NO.
Building Addreai: /1 a� O�x/ I/"4�J
G i I
r. sarre: ane:
W I _ CITY OF CUPERTINO-BUILDING DIVISION �_ GO
t� Ca testa .Nam: Nm APPLICATION / PERMIT C
9 BURDINGFI ECTRICALI'LUMBING-MECHAN'ICAL CATEGORY CONTROL/
Archltect/Fsglnaer. Llc No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address I IF PFRh9TISSUANCE ,()' u ❑ � ® � u
LICENSED CONTRACTOR'S DECLARATION '1
(hereby a(fimthatlamllce uMerpr onsof Chapter9(mm a APPWANCESd7FSDENIIAL JOB D[scRIPTR5N
Ingwlth5ectbn7000)of Dlvidon3 dthA Budwsand ProfeulonCode,and my
McCrae b N fuB and effect. 117 PANELS _.
Lice. Tact Lk.1 `i 1—I •^
Date oMnCOrUP TO 2DOAMPS
ARCHITECT`S DECLARATION
I urdenMand my plaro.hae be u iu publicmmdA. OVER I"AMPS I ®FI. 3/SQ.FT.
"Limned Prdembnal SIGNSEE{IRICAL
G 6 OWNER-BNLDER DECLARATION SPECIALCIRCUIT MISC T E_ R
7E, Therebyalflrr 03edthat Tamexemptfromthe Contractor's Cce.e Lyeity.e /
pp folbwing rca.mr.�edlmr7W15,Bwber aM l'rafmbu Code:Mytlty or
62 TEMP.ME-ITR ORIOLE(NST.
F� santy whkh requbesapermkromrobuct,alter,bnprow,dennWh,orrtpalr Q ' .
q anystroctum prbrrolb fa.uarice,aborequNa Neapp0antf«ouch permit to POWER DEVICES
k5 O a. file a alped statement that he b pursuantrobro Ileen ud to the pvlaof the
Q6 �� Contraetoi's Llceroe Law(Chapter9(mmmeneing wink Section 7000)of Divl- y}4y�{,VgNG POOL F].ECTRIC
ebn3.f the BuWeeand lode»bro Code)ortlut he bea themfromaM VALUATION
♦y the bub for the alleged exemption. My Wolatlon of Section 70315 by any
apph.t fora pemJt abject theapplbant to A tlWlperulty,des¢mom than OU=SW1TCIffSFD(TURES �O
w rw
endreddollar.(SSDW
LJ I,u owner of the Property,or my employees with wages as their sole NEW RESIDENTIAL ELBM SQ.ET. STORIES 'TYPE CONSTRUCTION
mmperuatlon,will do the work,andthntncture b not Intended or affnM for
O .;e(See.7044,Bwlnesaand Professions Code:The C.Mraetae.IJ¢me Law
j$ don not apply to u owner of property who build.or Improves theme•and KKK OCCGROUT' RES UNITS
who does such work himaeU«thwgh his own employees,provided that such
Improvemerd.arc not intended oroffemd for sale.14 hawevn,thewlldleg¢ TOTAL:
Impros mbaldwithinomyearofcompletlon,tF<ownerb MerwWbw
t"Men of proeing that he dw not wild or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE
Ll L u wvnn of the Property,am exclwhely contracting with 11¢need FLOOD ZONE APN
contractors to mrotmet the projed(Sea 70K Busbm and Professions Cade: / PEFI ISSUANCE Jaz_0O
The Contractor's Lkenne IAw does net apply to An owner of property who ALTER-DRAIN h VENL-WATER(FA)
bunds or imn ,pravin. and who contract f«such ptojem with a
9114AOwts)Ikeraed Pursuant to the Contractor's Lkeem Law. BACK FLOW PROTFiT.DEVICE FEE SUMMARY
LI I am eaempt urdn Sec B k P C for Ob mason
N
DRAINS FLUOR,ROOF,AREA,ODNDSA
. NIRY TAY_
Owner Dere _ —
KMANCOMPFNBATIONDECLARATTON RFLFR'Ta
❑I heWORreby affirm Nat I Fuv<a certificate of crosent to upyt self-insure,(Sa Fl%TIIRES I'FR TRAP SCI IOOI.TA% Y N
MM,ab ofWorken Cmnperuximinsunn¢«a¢rtdled copythereof(Secs - � Rcr7LI.T4
3800,Lab CJ - GAS Ia.SYSTEM-1 INCA OUf1ETS PARK EFR Y_ N_
PcIbe,
GD
Coray' CAS bT
EA.SYFT-OVER 4(EA) BUILDING DIVISION FEES
2CartMed ropyb hembytd. GREASE/INDUSTRL WASTE IIJTFRCFP'IOR PLANCHECK FEE
�,CenNed ropy b flied withh the dty lupe tion dfvWm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION WSURANCE SEWER-SANITARY-MRM EA.NIO.7 Date Remi lq
(TMs section need not od cu npleted If the pemdt b f«ane hundred doll
CA
DG)orlmJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I snotrtffy that o any person In of nr week so As to I thio pesubj 1e 1to the
I eha8 not employ any person In any rtunwDat u ro become vubjcct to the WATFRSYSIFM/TREATING
W«ken'CompnaHon lAws of UllfarMa.Date - PAID
C1 Z Appllcant NEW RFSDITRIAL PLMB. SQFI. Date RLreI I#
Z O NOTICE TO APPLIGINT:ILafler nutel this Certificate.(E.emptbR you
should become subject to the Woken'Compenaatbn prodebro of Ne Labor TOTAL:
N Code,you=at forthwith comply with ouch pm iuru or this permh.hall be 13UILDING FEE
] deemed rooked.
W CONSTRUCTION LENDING AGENCY SEISMIC FE
a Iherebyafflrm thatthembamrvtmdtmlendingagencyfortheperform- ELECTRIC FEE
Z arm of Ne work for which this perm0 b isved bee.3097,CW.C.) TOTAL 6•®� a
02 IAMer'aName PLUMBING FEE 0
LL I— Tender's Addmas QTY. MECHANICAL PERMIT FEE
O W Icenifythatl)uvemdthbappllotbnaMstatethdtheabove t.,,.utlan MECHANICALFLE
b.,reo.I agree to comply with all sty and county ortllnancee and Mete Owe I PERMIT ISSUANCE -OV FEES PAID:
} Il relating to wilding mntrectlon,•M1 hereby authorize representativafthb
Zety to enter upon the above-mentbrcd property for wpettbn purparn. ALTERORADDTOMECH Date Recci tp
V _ (We)agree to esus,Ndemrdty an d keep harmlea the City of Cu pertirm
Agabut BabWtlet,Pdgmerds,costs and expenn whkh may In any way aceue AIR HANDLING UNrr(TO IO,ODO CFAQ SUBTOTAL: .OV
against W d City In connque�d the gram Ing d Nb perreft,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX'
Signature of App0mst/Contract« Date ELI-IAtm'HOODM'/DUCE _�O CONSTRUCTION TAX PAID:
HALA R DOES MATERIALS DISCLOSURE
WHl the appEad«futum w0ding o¢v pant store or ha M le huardoun [(EATING UNIT(70 10,(00 ITIV), Date Recei tin
nut ial as deo red by the Cupertino Mu Ndpal Code,Chapter 9.1 7,and the
Hea rah and Safety Cade,Segbl M32p)7 FffATING UNIT(OVER 100,000 BTU) TOTAL: 161, 02
Yes [9'N�o
Dl the appliaM or Tutu re buBding occupant use Nu 1p nt or civ VENTILATION FAN(SINGLE RESTD) ISS - .•ATE
q
which emit hamrdow Air conte ants es defined by the Buy Area Nr
Quality hLvgemeM Out BOILER-COMP OHP OR 1W,"BTU) ABT 110
4 Y. o CVIR
havemad the h net matde,Seeona 255nnundernd 25534. 1 of BOIIFRCOMP(OV[R 100,000 BTU)
the Caldornb Halth A Safety Code,Setbro 8505,8533 and 75536. I
u p..aodyt..that tLfy th nott r,egt)yham,a hanLthmt trey NEW RISIDFMIAL MECH. SQFI 1MM rt/1�
ruporoissuar eo(aytha ottvpaddtparuyuimmeMe whkh nest be rret vR�N 'U IRIII.,.E "Y„L]J
palm to lavarux daCertlflotc of Ocvpamy.
Owner or authmired agent Date ISSUED BY:_
TOTAL
OFFICE COPY