22222 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification PERMITNO.
Balding Address: C*.,S P../ n n n
e 20400 Mariani Ave. , Cupertino, CA 95014 dr�C" Ad G G G
22
Owners
ntex (USA) Inc. 5 p' m�e.
SCITY OF CUPERTINO-BUILDING DIVISION A
Contractor's Name:
C0-172486 Lic.Na APPLICATION /PERMIT
Schwartz & Lindheim Inc. BIRLDINC-ELECTRICA MP BING-MEOHANICAL CATEGORY CONTROL
IRW Architect/Engirser. Lk.No:
Paxton Minert BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Adlens: 2033 Concourse Dr. , San Jose I PERhIITISSUANCE CSG
LICENSED CONTRACTOR'S DECLARATION s. El IK D
I hereby affirm that l am licensed under providons of Chapter 9(commenc APPLIANCESRESIDENfIAL JOB DESCRIPTION
ingwith Section7000)of Division3 ofthe Businessand ProfesslonsCode,and my
licenm is In Mimed rad effect. PANELS
Lunar Clam —� LIc.X 172486
DateContractor x
ARCHITECT S DECLARATION 701-IOW AMPS
o7d I understand my plans shaBbe used n public reosrds. OVERiwo AMI'S � ,-F�Ii�O` EA S/SQ.FT.
Z Licensed Profemional SIGNSEIECTRICAL UT
;1 p�
«<�< OWNIUER-BUILDER DECLARATION SPECIALCIRCUIT/MISC C
i„ (hereby a(Orm that]cum exempt from the Contractor's Llcense lawfor the
7
09/I:.� following reason.(Section 70315,Business and Professions Code:Any city or TEMP MErERORPOLEINS. 7 a`//�/
p county which requireaa permit toconatmct,alter,Improve,demolish,orrepair
C y�yS.'ai anystm=m priortolts bmaaoce,alsorequirestheappliant forsuch permitto POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
04 Contractor's License Law(Chapter 9(mmmencing with Seaton 7000)of Divi-
sion3ofthe Business and ProfessionsCode)orthat he b VALUATION exempt therefromend SWIMMING IDOL ELECTRIC
Sn the basis for the alleged exemption. Any violation of Section 7MI5 by any ETSSWITCI{ESFIXT[JRFS
<5, applicant for a permit subjeasthe applicant to a civil penalty of na morethan 1
w o five hundred dollarspro e e NEWRESIDEN7IALELEC7R SQ.FT. NSntUCTION
t
GGG777 7 a ❑I,as owner,of theheproperty,or my employewith wagas theirk Ir socompensation,willdothe work,and thestmeture Is cm intended or offered for
S O sale(Sec.7094,Business and Professions Code:The Contractors License Law .)
$ does not apply to an owner of property who Wilds or improves thereon,and ATR—C0%'*. yt,�, OCCG ' .I1NIT5
whodoessuch work himselforthrough hisownemployees,provided that such
impmvementsarenotintendedorofferedforsale.l(howevegthebuildingor TOTA : e �-I-E
improvementbsoldwithinoneyearofcompletiorytheowner-b gderwillhave
ili,etarden ofproving that he aid nawRaorienproeefrrpurpo:¢Mule.). QTY, PLUMBING PERMIT FEE
LJ 1,as owner of the property,am exclusively rontraaing with licensed FLOOD ZONE APN
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereoM and who contracts for such pinlecb with a
m�B(actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this reactorsOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
' Owner Date RECEIPT It
WORKMAN COMPENSATION DECLA RA TION pLYTURES PER TRAP
RECEIPT
TAX Y— N—
❑I he
.(fire,that I have a cenifiate of consent to ENV-mwrq or a RECEIPT x
renifiateofWorken Compensation lnsuranceora certVbd ropythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab —
Poliq p
RECEIPT X
ray
GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified espybhereby furnished. CRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. DaIC
(This section need not be completed If the permit b for one hundred dollars RCCCI IN
(5100)orlem.) WATER HEATER w/VENT/E.ECTR ENERGYFEE Y_ N_
I certifythat la the pcAsmancerf the work forwMeh fhb permit b Lmued,
1 shall not employ any person In any rtunner so m to becorre subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
OZ Applleint NEW RESDENnALPCMB. SQFT. Dale Remi t#
Z O NOTICE TO APPLICANT.R,after making this Certificate of Exemption,you
should become subject to the Workers'Compersation provisions ofthe Labor TOTAL:
W Gude,you most forthwith comply with such provbmn orthl,permit shall ba BUILDING ..
seemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
11 Hurebyaffiren that there Is a construction lendlegagency,forthe perforrry TOTAL: ELECTRIC FEE aW
7 Z ance of the work for which this permit is Issued(5-1.3097,the.C.) PLUMBING PEE
LLO Zanders Nanta TY. MECHANICAL PERMIT FEE
LL I— Lenders Address Q MECHANICAL FEE
O W Irnect. ail have read lhL+appVatlonand aatethat thcaboveln(ormatlon
rretobuileetoeomplywith and hereby
rouhriers repreesand ctsofthis PERMIT ISSUANCE FEES PAID:
} W mistingoenterulpongmnovereatimud rcbyauthorize representatives of this
city(We)areetoraveindermtifyaned property Cit purposes. ALTEROR ADD TO MECH.
2 (We)agree b save,indemnify an d keep es which
the City of Cupertino Date ReOTAL
V ,(r against 11 tles,j.tdgmenb,msband expenses which may in anywayacaue AIR}3ANDENG I1NIl'(TO 10,000 CFM) SUBTOTAL:
against id ityincony lie ftq aFe,P he granting of this res .
AIR HANDLINGUNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S ntureof Applicant/Contractor Date Ext AUS'T HOGG(W/DUCT) CONSTRUCTION TAX PAID:
X HAZARDOUS MATER[ALS DI SCLOSURE
Will the applin rat or future building occupant store or handle hamedous HEATING UNIT(TO 100,ODO BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)P HEATING UNIT(OVER 100,000 BnTOTAL:
❑Ye MN.
Will the applicant or future building occupant use equipment or devices VENTI IATION FAN(SINGER RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3 POR 100000 BTUs
-
yes
No
haveread the haze materials requlremcnb under Chapter 6.95 of 00ILFRCOMP(OVER 100,0008111)
the California Health&Safety Code,Sections 25505,75533 and 25534. 1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MSCI I. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. ,
Owner or authorized agent Data TOTAL: ISSUED BY: -
OFFICE COPY