23211 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification . - PERMITNO.
Building Address: 23211- .
wneraante. %A/Z _ one90 CITY OF CUPERTINO-BUILDINGDIVISION
co nadoraName: Lle.Nix APPLICATION /PERMIT !�
wAA MI UI
BLDINGELECTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL#
rchftect/Enginesc Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRunder $DECns of Ch ON
- ]hereby affirm that lam licensed under provisions o(Chapter9(commenc APPLIANCES-RESIDENTIAL ]OB DFSC '1TON '
Ingwith Stion7170ce0)ooapff D�lviafon3�olfthhee B'u�sin`ess/and ProfessionsCode,and my
Been
PANELS
LlceneelClassCfY 10L��N oZSoT/�J
Date ] � Contrator CHA N q N1rLdUP TO 2DO AhVS - -.apn•
ARCHITECTS DECLARATION 211-1000AMPS l&
Zqq I understand my plans shall be used as public records OVER 1000 AMPS 'SQ.FT.FLOOR AREA : 5/SQ.Fr.
E do U Lloenad Professioml SIGNS ELECTRICAL I N
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@OBUILDERDECLARATION o
1 hereby SPECIALCIRCUIT/MISChatIsmexemp from the Contractor'sLicense Law for the
9 following rreason.(SedlonQ B and mfdgmrxCde:Anydry TdP.METER ORPOLE]
NST.
® M P T R
FOontywhihrcqulrcsapermttocomtmd,ater,bprove,deml0h,orrepait
�j
q anystma mpriortoibissuance,alwrequbestheapphmniforsuchpemdtto pOWIER DEVICES DATE Gr
L U file a signed statement that he is Bcenssd pursuant to the provhlons of the
�3 ContractoreLicense Law(Chapter 9(wmmencingwith Section 7000)ofOwl. SWIMMING POOLELECIRG
O slon3 of the Business and Professlons Cole)orthat hely exem therefromand VALUATION
QY.' the bash for the alleged exemption. Any violation of Section 7BH.5 by any
<05 appnant fora permll aubjeda the applicanuoa dull perultydnt morethan OVfLElSSWITCIMFSFlXTURES 0
$i five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES (V'jVJ TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
k2 compensation,will Bothe work and thestrudureh not Intended or offeredfor '
5 O giIn(Sec.7044,Bualec.and Prefesdmo Gods:The Contractors License Law ,
�$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.IINRS '
w who does such work himself or through his own employees,provided that such
Improvement are not mtendd oroffered forsale.If,however,thebullding or TOTAL:
improvement h wld within one yearofcompletlon,the owner-W dderwill have
thsbardenof provingthat he did not bund or Improve forpurpowof sale.). QTY. PLUMBING PERMIT FEE FLDODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PFRMTTL%UANCE
contractors to construct the project(Sec.7044,Business and Professlom Code: -
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilda or Improves thereon, and who contracts for such ptojeds with a FEE SUMMARY
,,00.�trador(a)B¢nxd pursuant to the Contractor's Llcenae Law. BACK FLOW PROTECT.DEVICE
I_I I am exempt under Sec. B& P C for this mason
Owner Date DRAINS FLOOR ROOF,AREA,CONE. SANITARY. Y N_
. t herWORKMAN COMPLNSATION DECLARATION RFGF7PI#
{Jeby afflrm that I have a aa
ti0cate of consent to self-inane,or a ��'I�TRAP ' SCHOOLTAX Y_ N
adiflrneof Workers'Compe�ationivunnmwacertlfis mpythemoft5ec. - RECFlPI0
3800,Isis C.) , GAS EA.SYSTEM-1 INC-4 OUTLETS PARK FEE Y_ VI
N_
1'oliryY - G GAS EA.SYSTEMOVER 4(EA) RECG
- �m nv ntno ccA SFATE.i Bunrnlvc OflnlsloN FEE
I&
Certinea copy h behhd. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
cemnd copy h mead with
im t the dry Impetmn awhmn.
CERTIFICATE OF EXUAPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2JOFC. Date Recei t#
(This section need net be completed if the permit is for one hundred dollars
(SIM)or leas.) . WATER F{EATFR w/VENT/ELFGTR ENERGY FEE Y_ N—
I
-
I od ifythat In the performanneof thework forwhlch this permit isissued, —
I shall not employ any person In any manner w as to become subject to the WATER SYS713A/TREATING
Workers'Compensation laws of California.Date _ PAID
OZ Applicant NEW RESIDliN77AL PLMB. SQ.FT. Date Recei tN
Z p NOTICETO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Workeri Comperuation provisions of the Labor TOTAL:
CC N Code,you=at forthwith comply with such provisions orthh permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirrnthat there is a construction lending agency for the perform- T T ELEC'T'RIC FEE '
M Z ante of the work for which this permit hhsued(Sec.3097,Civ.C.)
0 Lenders Name PLUMBING FEE ,
F Under's Add mas QTY. MECHANICAL PERMIT FEE
LL U . l cetBythat I have read this application and tate that the above information MECHANICALFEE
O W Is correct.Iagree to comply with all city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID:
} a relating to building construction,and hereby authorize reprosentalives of
F N city to enter upon the above-mentlond property for Inspection purposes. ALTER OR ADDTO MECH.
? (We)agree to give,Indemnify an d keep harmless the City of Cupertino Date Receipt#
U gaingil.bi[Bidt,' dgme s,cotsandex nae hlhmay In anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal sal ti n II I orictima in
Sig% d--•C ^ '��E ^��a AIR HANDLING un'IT rovERla,000cFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date D(HAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID: ,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occv pant store or ha ndle hazardous HEATING UNIT(O IOQODO BTU) Date Recei tit
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Iiealth.odSafety Cod SectEA
ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1Yea o
Will the a pplicant orfuture building occupant use equipment or devices VFNDLATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hairs rdous air contaminants as deli ned by the Bay Area Air p•N -
Quality Management Dist t7 BOILER-COMP OHI'OR]000(0 BTU) r.p '
4Yea No M
have read the h o materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Californial7calth&SfotyCode,Sediov25505,25S33and25534. I FEB ,. 7
understand that if the building don not currently have a tenan4 h that It my NEWRFSIDENITTALMEM. SQ.FT 1992
rnpomibiliy to notify the pant of the mgulreme which must be met
prior to I.Ance aCertI at tvpan CI7r(h: s
BY.
LIP
Owner or authorized 6.... Date TOTAL:t IMBUED BY:
OFFICE COPY