21899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification l n PERMIT NO.
Building Address
/�0 .6 2— /y4 wi - 5 / 2�.c{' �Gf 21899
�' one: A
wnera.'SQ //'1 71' /rel 4co CITY OF CUPERTINO-BUILDING DIVISION
•� Contractor's Name:— TCP ic APPLICATION 1 PERMIT
f Sf AS-La'tC �j CATEGORY CONTROL If
Architect/En neer BUfLDINGELFGTRICA4PLUMBINGMECHAh1CAL
gr' Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE '] m W F�f ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APpL)ANCESRFSIDENITAL LP
I hereby affirm that I am licensed under provisions o(Chapter 9(mmmenc JOB DESCRI[TION
Ingwith Section 7000)°( ' op�fthe Buslnnsand Pro IonsCode,a m
License l in(u o (ed. ^� & 1 PANELS ,r 1� .
LlmnasC i a CA
Dale Contractor
ARCHITECrS ACLXRAOfION 201-1000 AMPS
Z I understand my plain shelf be used as public records. ( OVER IODO AMPS SQ.Yr.FLOOR AREA S/SQ.FT.
00L IN
Fj Llmnsed Professional1 SIGNS ELECTRICAL A L E D
6 ° OWNEReBUILDER DECLARATION SPECIALCIRCUIT/MISC 6�II p U T E R
soving affirmthatlam31.5,B from the d Ponfe to Lloonse Law for t he
following recon.iSection 703L$o Business and Professions Code:Any city or
F s'�
county which requlrtsa permit tocomtruR,alter,improve,demolish,or repair TEMP.MEITR OR PoLE INST.
any structure prior to Its Issuance,also mile lres the applicant for such permit to
3 file a signed statement that he Is licensed pursuant to the privIsiom of the TOWER DEVICES09AT
Ow Contractors License Low(Chapter 9(mnomnnWg with Section 7000)of Met- SWIMMING POOL ELECTRIC
O snon 3 ofthe lbignessand llofeabmCode)orthat he Is exempt therefromand C� VALUATION
59 the basis for the alleged exemption. Any violation of Section 7Ri1S by any
�uh0 applicant lots permit subjects the applicant to a civil penalty of not-5 by
OIJTLETSSW[TCIIESHXTIIRES
five hundred dollars(5500). NEW RESIDENI7AL ELECTR
L as owner of the property, 50.Ft� SI'OR1ES TYPE CONSTRUCTION
,Z 6 p perry,or my employer with wages as Their sole
compensation Business aworkandions Cdureh notintended oroffered(or
O sale(Sec.apply
to an ow and f property Code:The Contractor's License law
[�js$ dmenot
such roan ownerofproughhis obuilds nemorimproovided that such
OCC.GROUP RES.UNITS
G whodmsa tsamnkh to dedoor roughhisownemployer,er,the dthatoch S
improvemrcnb are not intended oroftered foraale.[Lhoweve;lhebulidingm TOTAL:
Improvement Iseold within one year.(compldion,the owner-W Bderwill have
ths.lzurden of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEEpl,pp ZOONE APN
L as owner of the property,am exclusively mntncting with Il 1— PERMIT ISSUANCE
contractors to c°mtmud the project(Sec.7064,Buslnem and Professlom Code:
The Contndor's License Law does rat apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pt -
ojecta with a
cgRlfadm(s)ficensed pursuant Is the Contractor's License Law. gACjtp�y�r PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
Owner Data DRAINS FLODR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT 0
❑1 hereby eifirm that I have a conificits of consent to self-insure,m a FIXTURES-PER TRAP SCHOOLTA% Y N_
f ormfiateofWorkera Cam rsaifon lnwranoo ora certlfiedcopy Nemof(Sec. RECEErra
3800,Lab CJ GAS EA.SYSITM.I INC.4 OUTLETS PARKFFE Y_ N_
Pollry M 4p
Com anv A. 5 �'� x, Psis M r is r GAS EA.SYSTEM-OVER4(EA) BUILDING FEES
LkdC Cert ed copy is herebyfurnished.
CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
rtified copy Is filed with the city Inspection division.
CERTIFICATE OF O(EMPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA Date Remi t#
2AOFT
QM section need nor W completed if the permit Is(.more huntlred dollars
(SIM orlesa.) WATER HEATER W/VENT/EECTR ENERGYFEE Y N
I comfy that o she ped.on in any
the work so at to b this penult Ic Issued,
I shall not employ any nems.^In any runner so u to become subject to the
Workers Compensation Laws of Glllomla.Date WATIR SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,Fr, Date Remi t#
Hshould become subpot to the Workers'Comperoation provIsiom of the Labor TOTAL:
WW Code,you most forthwith comply with such provisions or this permit shalt be
> deemed revoked. BUILDING FEE L
tl E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE 6
I hereby affirm that them Is a mmtmdion lending agency for the perform TOTAL:
M O ance of the work for which this permit b,Wued(Sec 3097,Civ.C.) ELECTRIC FEE
0 _ I<hderb Name PLUMBING FEE
LL I— lcndce.Address QTY. MECHANICAL PERMIT FEE
O W Imrtlfythatl have read thlaapplicationand autethattheab°ve information MECHANICAL PEE
1 iscorred.l agree to comply withal]dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} Nrelating to building mmmiction,and hereby authorize representatives of this
Z city to enter upon theaWvnnentiorud property for Impaction purposes. ALTERORADDTOMFGH.
— (WC)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,"a and expenses which may In any way ace,oe AIR HANDLING UNIT(To I0,0D0 CFM)
against said City In comequ shoo of the granting of thts permit. SUBTOTAL•
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Apphont/Contractor Date EXHAUST HOOD(W/DUCT - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBont orfuture building occvpard store or handle hanrdoa HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.IZ andthe Date Recei t#
Iicalth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑ Yes ri No TOTAL,,
Will theapplicant orfututo Wilding occupant useequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hru
ardous air costamlmnts as defined by the Bay Area At, -
Qu lily Managenrnt DlsWctT BOILER-COMPQHPOR 100,0(10 BTU)
Yca ❑No
�- have read the haurvfous matenaLs requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 RTU) r luij
the California Health k Safety Code,Sediom Z505,25533 and 25536. I 1
understand that if The building dor not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT rih.�
rrponxibility,t9fluctilytheompa of try^ creme whkhnwstb,,.
prior ia• ora tl Intl a {¢� l /7�/ / i �.CI:• (j ,-
TOTAL: ISSUED BY:
OFFICE COPY