24074 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
nwlam Project en Identification1R
lon rhnT NQ, 4 0 7 4
,. Bullding AddfcBu
_ oS3al t40J
T5=1
il
CITY OF CUPERTINO-BUILDING DIVISION �� q
centrador'.Mme: - Lie.N. APPLICATION /PUMIT
litupm Co./IsTO.✓ LO. BUILDINGEECTRICALPMUMBING-MCAL CATEGORY CONTROL v
Archltcct/ glrxw Llc.No:
IA� BUILDING PERMIT INFO
QtY ELECTRIC PERM - PEE.
Address: AV�/. �'1
PERMITI5SUANCE
1" LICE CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmsee APPLIANCFSRESIDE L OB DESCKB'TION
ing with Section 7000)of Division o(the Buideca�sannd Profe&sloesCode,and my
/��}^
liana I.in fu arect. S , Y I�Y� ^
jXTQ
an
PANELS
Ll ' Clan Lic.M JOQ ss'
Dae Contractor �/a,/
ARCHITECTS ECLARATION p1'SAM
0Z I nderstand my plan.hall be used u public record&. V 000 SQ.Fr.FLOOR AREA S/SQ.FT.
O
Licensed Proferelonal CAL % Lkq
1O
6 OWNER-BUILDER DECLARATION TALC
7E, IherebyafRrrn that l am exempt(romthe Contractor'.Llan..Law for the -
pp following reason.(Section 7Rd15,Buainee&and Profenlons Code:Any dty or
TIP.ME INST.
FE cmntywhich requlrcsa permittomvtmct,ater,lmprove,demolish,orrepalr
a anystrocture prior tolts Issuance,also requiresthe applicant torsuch permit to POWERD
PVV
ryC U file a signed statement that he is licensed pursuant to the provisions of the
04 Contract.e.License Law(Chapter 9(ce..eingwith Section 7000)ofDivl-
�0 gan3o(the Businns end pro(emlovCode)orthat heisexempttherefromand NG LELECTRIC - VALUATION A�
yd the basis for the allegmi exemption. Any violation of Section 7031.5 by any O �I
aPpliant for a permitsubjecta the applicant to a civil penalty a not moa than I17LETSSMTCFIFSEXI'UItS V ,
By hundred dolts.($SM. NEW RESIDENTIAL ELECTR SQ}T. STORES TYPECONSIRUCTION
as owner of the property,or my employees with wages as their sole.
mmpensation,wfll doth.work.andthestmmm isnot m ended or offered for
❑ vie(Sec.7044,Business and Professions;Code:The Contractors License law
does not apply to an owner of property who Wilda or improves thereon,and
EEE whodoce such work Mmelforlhrough his own employees,provided that such OCC.GROIIP RES.UNITS
Improvements are not intended proffered forsals.If,however,thebullding or
Improvement hsold within amyearofcanplelogtheownerbuaderwRlhave
tllEtIurden of proving that he did not build or improve for purpose ofsale.). QTY. 'PLUMBING PERMIT FEE
u FLOOD ZONE APN
as owner of the property,am exclusively Business
contracting with IlaneclconPERMITISSUANCE ,r
The Contractor's
to rovWd the project(Sec.or apply
Business and Pf prop rt Codo
The Ceor Improves
Llane Lew don rat apply to an owner.of property who ALTER-DRAIN&VENT-WATER MA) -
huBda car Improve thereon,and who mntnN for each p(ojeca wRM1 a - FEE SUMMARY
m,R((adwW licensed pursuant to the Contractor&License Law. BACK FLOW PROTECT:DEVICE
I_l I am aempt under Seo B k P C for this reason
1DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMANCOhIPENSATIONDECLARATIONpp( q,PER MAPSCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to aelf4esure,or a - RECEIPT N
3NWrlmteotC.Works Compevatlonly mnaoramnitledmpythen f6l . GAS RA,SYSTEM-1 ILNCAOUTLETS „� PARK FEE Y N
Polity tl •. GAS EA.SYSTEM-OVER d(EA) RECEIPT N
Com ray ,pyyp �-f Q� BUanwc orvlsloN l'r:Eg
�Certled copy is here ml ed. GREASE/INDUSfRL WASTE INTERCEsTOR PLANCHECK FEE ,I. C—Do
O
Certified ropy is filed with the city inspection division. _CERTIFICATE OF EX EM PITON FROM WOR KERS' GREASE TRAPA1000MPENSATION INSURANCERhiswdlonneednatbecompletedlfthepert tisforonhundreddollars '`EWER-SANITARY-STORM EA.l00Ff.(Stm)orles+.) WATFA HEATER W/VENT/ELECTRENER�cy F Y_Imrtlfythatlnt nype or.a ..Yt nnerf "tchthis sybjisWthe —L ��Ishallnetemployanypersonf anymanneraontobemnn bkdtothe
Workere'Compenvtlon Laws
of California. Date �' n PAID
O Z Applicant i� Datil 1.Inn
Z G NOTICE TO APPLICANT.If,ager making this Certificate of Exempt) n,y LMB
should become subject to the Workers'Compeva ion provlslonso(th T TAL:rl
�.ta
N Code,you must forthwith mmplywith such provislev orthispermit al BUITM FEE VO
LU > domed revoked. SEISMIC FE
CL G CONSTRUCTION LENDING AGENCY
I herebyef(irm that them iso mretrudion lending agencyfor hoper(o ELECTRI '
M Z ante of the work(or which this permit Is Issued(Sec.3097,Cie. Al,3ifK W5
U O Lender.N.me PLUME G 'E
1L F Lender's Address QTY. ' •' MECHANICAL'PERMIT 1 FEE MECFIA ICAL E
OW . I witifythatl have read this.ppliatbnandetatethattheabovelnformation
1 .famered.Iagree to complywlth all city and county ordinances and gate laws PERMIT ISSUANCE FEES I
} relating to building construction,and hereby authorize represenmtivesotthis -
(. city to enter upon the above,mentioned property for Inspection purposes. ALTORADDTOMECH.
Z
fWe)agree to nave, deme fy an d keep harmiem the City of Cupertino - atc +RCCeI NI
V against liabilities,Ndg ets,mgaand ez see soh¢¢heray]nany way come AIR HANDLING UNIT(TO 10,000CFM) UBTOTAL:
agamatvld Ci C e ofthe gr' tin Ehl&pennlV f
z
I/ AIR HANDLING UNIT(OVER 10,O30CIM) fCONSTRUCTIINTAXSigresfa /Cortr nor D m IXFWUST HDDD(w/DUCp TRUCTAX PAID:
HAlARDOUS MATERIALS DISC URE
theapplicant orfutum building occupant store or handle hazardous FTFATING UMT(T0100,W0 BTl.n ice' te 'Rece tN
mat Ices defined by the Cu peg]no Municipal Code,CM1aptcr 9.R,and the
Heal and Safety Code�+Section 25537(.)7 HEATING UNIT(OVER 100,000 BTU)' TO ,
❑Yes ,II+��--11,�No i M
Will theappliant"Future bu]Iding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) L./� ISSUA EDATE
which emit hazardous air contaminants as cleared by the Bay Area Air -
u�IityManagement District? BOILER-COMP pEItDft 100,OlU BTU)
4Yn �No
have 1.11t eth& f,ty C.edal at..lrementeunderCM1apte4.1 of BOILER-CAMP(OVFR 100,000 BTU)
the Glllomla lleallM1&Safety Code,Sections 7550.5,75533 and 25534.]
understand that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be mar P .411
/� {4 y
prior to Issuance of a Certificate of Occupancy, 4,'v Po,i
Owner or authorized agent t Date - ISSUED .�OI i
TOTAL:
OFFICE COPY CITY OF cbrCt..tr