21380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project lJemlflntlon PENMITNO.
Building Address: QZ 21380
1 ^8 O
LO I I�I Q G lSJ 7lSJ
caner. ante: one:
eaut C I Q.NJ('KS "ZL5 3_q 14-1 CITY OF CUPERTINO-BUILDING DIVISION b (-?Z)
� I,�
Contradoes Name: Lit N. APPLICATION /PERMIT MvR� a(
-� Archloct/Engineer. Li.Na: ' BUILDINGF7.EC7RICALI7.I7MBINGMECHAMCAL CATEGORY CO V t, 10
-
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Address: 1255 KjS�6DTW�,70 4. 57'ej51 PERMITISSUANCE � �QD ��(117) �r/a�y
LICENSED CONTRACTOR'S DECLARATION I�T R�
I hereby affirm that l son licensed under provisions o(Ch.p1er9(cemenen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Section 7000)of Divisloo3ofthe Budinessand ProfesslcnsCode,and my - -
liceneelclass l(om and Lit
PANELS
I...Clam LIO N
Date Ccourt
ARCHITECTS DECLARATION 201-1000 AMT'S
97 I understand my plans shall be used as public records. OVER IODO AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
s�OO
f4 �j Licensed Professional - SIGNSELECTRICAL
< N
< OWNEReBUILDER DECLARATION
� S['ECIAL CIRCNT/MISC
.77r1 owing reason,
Sectio 70315, tfrom the d Professions
Coe:law fort he , U
oo following remon,(Settlors 7071 S,Business Pm(evlone Cade:Any
09-..� _ TEMP.METIS OR POLE INST. l
F� countructum prior teas permit hatiane,ceomquirstheartatruct,all., provgdemolbh,orrepalr
any attudurepaterento t that he Is akensed pursuant
to
the
revisionsormuch of to " POWER DEVICES
file a signed statement that he la Ikeroed pursuant to the pmvlalotu a( the _
Ow Contractor's Llcerae Law(Chapter9(cemmencing with Section 7000)of Dlvl-
30� Y3oflheBudines...d Professlit.Code)or that he is exempt therefmmand o��'�NC IC]OL ELECTRIC
on ^ VALUATION
- G the Web for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWITCHESHXTU9 RFS' / 3 6 /70
applicantfora permit subjedsthe applicant to a civil penalty of not more than
five hundred As
ewner of thepr). NEW RESIDENTIAL ELECTR SQ.Fr. -STORIES TPECONSTRUCTION
�n ❑I,sa owner o!the property,or my employers with wages r their dole
<
compensation,Nee. 044,will dothe work,and the Cde:Tho to commended o License
d for
L.. our O 2
O sale Nee.7044,to alnowand f property Code:The Cmuraorimpcto/a LicenseTaw 1doos not J
r$ whodoesucti toanownel of f or throng ywho bu mpoympmovidedwas rthatand , OCC,GROUP RES.UNITS
EEEEEE whodoement,a ran
Nsowneed .If,
tidedilding oruch , L0
Improvement issold intended caro omplation,th howeveAthe WildNgor TOTp)� 4
Improvement beoW withinoneyxaro(complYion,tha ownervW Ildcrwlli have '
t�rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBINGPERMIT FEE FLOODZONE APN
1,as owner of the property,am exclusively contracting with licensed pFRMIT1SSUANCE
contracmn to censuud the project(See.7014,Business and Professions Code:The Conant License Law does no apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilde or Improves thereon,and who contracts (or such pso)ecta with a - FEE SUMMARY
cgp .d.e(d)Ilren.d pursuant to the Cont.dore Llcense Law. gpp0 FLOW PROTECT.DEVICE "
LI I iur mpt under Sec. B&P C for this mason _OUTSIDE Pi
DRAINS FLOOR,ROOF,AREA,COND, SAMTARY Y_,N
Owners Dain RECEIPT N
- VORKh AN MPENSATION DECLARA ON pp(nHgq,PER TRAP SCHOOL TAX Y_ N
E31 hereby affirm that I have'.mrtigcam of consent to self-Ineure,ora RECENT N
certlflnte&Workem'Compewtlon Insurance or a certified copy thereof(Sec.
3R0D,Iab CJ CAS EA.SYSrEN-11NC.d OUTLETS PARK FEE Y N
'
Policy N GAS EA.SYSTEM-0VER 4(FAJ RECEIPT N `
Com any - BUILDING DIVISION FEES
[rCedlged copy is hereby fumished. GREASE/1NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑cartmed copy is filed with the city Inspection diviron. -
CERTIFICATEOFEXEMPTION FROM WORKERS- CREASETRAP 'PAID j0
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.2()(ST. Date Rewi ted -
(�his sedlon need nb completed if the permit b for ane hundred doliam p
(5100)orlassJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenot thatlnthe Person inannce tnumnerhe work forwhlchco exubPermleeitotheonted, q ..cart
I shall not employ any Laws In any manner eo rs m become subject to the WATER SYSTEM/TREATING F
W plicanCompeneabon Laws of California. Dale - PAID
Z.Z. Applicant' �: NEW RESIDENTIAL PLMB. SQFT. - .. Date Reml fif
0 NOTICETO APPLICANT: making this Certlflrate of Exemption,you
Hshould become sub)ed to the Workem'Compomat ion provisions of the Labor ' TOTAL:
ccN' Code,you—at forthwith comply with such provlsli ser this permit shall be -
W G deemed revoked. BUILDING FEE ezo
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affi mthzt there is a construction lending agency for the perfortm ELECTRIC FEE
Z ..m.fthe work lorwhlchthi.permit Is Wued(Sec.3D97,Chr.C.) TOTAL; -
dro
U Q lender'.Name PLUMBING FEE
LL F ' .Lend.e.Address QTY. MECHANICAL PERMIT FEE kMECHANICAL FEE (00
O W Imrtilythat l haveread thisapplicatlonand Yate that theabove Information
1 Isommo.I dgreeto comply with all dlyand countycrelinarmand Yatelaws PERM!" ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
Z _ city to enter upon the above,menlloned property for inspection purposes. ALTERORADOTOMECH. Date ReCei fk
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
against llabillt lee,judgments,costs and expenses which may In any way accrue AIRFIANDLINGUMT(r010,000CPM) SUBTOTAL'
a ahot a City In con en of the granting of this permit
`. AIR HANDLING UNIT(OVER lO,ODOCFM) CONSTRUCTION TAX
ureo(Applicant/Contractor-' Data FxHAusTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate RCCCIptfl 71
aterial as d4oed by the Cupertino Municipal Code,Chapter 9,12 and the - y
Health and Safely Coda Section 25532(a)7 HEATING UMT(OVER Iffy"RTU) TOTAL:
❑
Wlllthaappliranlo,to building ouvpart we equipment or device VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emararionert aRconlamlmnts as deMedby the Bay Area Air
Quality Matutgement Doorict?cmd BOILER-COMP(3tIP DR IOO,IXp BTU) -
Yes ❑No
vc read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,00013TU)
the California Health&Safety Code,Sections 25505,25533 and 2534.l
undentandth.tlfthebulldL.Sdownotarmntlyhaveatenangthatitbmy NEW RESIDENTIAL MECH. SQ.Ff.
responsibility to notify the occupant of the requirements which must be met t
prior to issuance of a Certificate of Occupancy.
t
Ownct or euthorlecd agent Date ISSUED
- TOTAL: '
OFFICE COPY