21612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE ALL POINT P N ONLY
Building Project Identification 0t PERMITNO.
Bd
Ba .ng Address: a� 25 o � SaH ' 4�ate/
I 21 61 2
Name: ((�� FO71I�t.0/�
A'
w^era _ aJ _a��- CITY OF CUPERTINO-BUILDING DIVISION
ca^ Lie,Nm APPLICATION / PERMIT
BE ILDINC-ELECnUCA4ML BINGMECHAMCAL CATEGORY CONTROL p
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PFRMITIS5UANCE - '❑ �]l ❑
LICENSED CONTRACTOR'S DECLARATION IBJ
I hereby affirm that l am licensed under provisions of Chapter9(comount APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Setion AlOWot Divlsion3ofthe Buslnessand ProfesalonaCodr Brut my
license is is full force and dfeat. PANELS
LicenseChss Llc.p - -
Date Contvctor
ARCHITECT'S DECLARATION - 201-1000AMI5
pq+mO ZpC I understand my plans shall be used as public records. OVER I ODO AM PS SQ.FT.FLOOR AREA S/SQ.FT.
F Z U Licensed Professional SIGNSELFCTRICAI,
7�d 6 OWNER-BUILDER DECLARATION
�x Ihereby affirm that lam exempt from the Contractor'.License Law for the SPECIAL NT/MLS( '
O 9P.. (ogowing reason,(Smion 7W iS,Business and IProlesabns Code:Any dty or TEM M " OR PO
t-' countywhi6mqulresapert ttowmtmd,alter,impmve,demolbh,ormpair
Y��C6at any atmdure prlorto its asuance,alao requimstheapplicant for such permit to
C V file a signed statement that he b licensed pursuant to the provisions of the CF
�a t Contractor's License Law(Chapter9(commencing with Section 7000)ofa I VALUATION
O sion3ofthe Business and Professions Code)orthat he b exempt therefromand
Yi 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any E n
apphmnt fora permit subjects the applicant to a civil penalty o!not more tha
otl hon dollars(5.500). NEW ftESID AL FT.
Q ,as owner aof rs(I property,or my employees with wagm a their a e c� STORMS TYPECONSTRUCTION
coin nss0on,willdothewark,andthestruchomianot intended or otlered fo
C O sale .71144,Buabreni and Profemions Code The Contractors Lice
does not apply to an owner of property who Wilds or Improves thereon•and
'$^ who does such work himself orthrough his own employees,provided that such OCC.GROUP RIS.UNITS
Mprovementsare not intended proffered lorsale.ILhowevegthebuildingw - TOTAL:
Improvement bsold withinoneyearofeempletion,the owner-bullderwill have
fllt;inrden of provmgthat he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ,sem
contrseton to construct the project(Sec.7614,Business and Professbnv Code: ?s
The Contractor's License Law does,net apply to an owner of property who ALTIIt-DRAIN kVENT-WATER(FA)
builds or Improves thereon,and who contracts for such ptojeaa with a FEE SUMMARY
L6actor(s)licensed pursuant to the Contractor.Lima.Law. BAC(F(piy PROTECT.DEVICE
I I am exempt under ser. B A P C for thin reasonOUTSIDE FI I'S
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Data
gFCp-B.p p
WORKMAN COMPENSATION DECLARATION FIXTURE_&PER TRAP SCHOOL TAX Y N
F11 hereby a/firm that I have a certiBceconsent te of coent to self-insure,or RECLSPT p
cediflcate ofWorkeri Compersatloniwurance ora certl(kd copytherm((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N-
3800,Lab C.) RECEIPT tl
Policy a IT GAS EA.SYSTEM-OVER 4(EA)
ny BUIL DING DI VISION FEES
citified copy is hereby furnished. GREASE/INDUSTHL WASTE INTERCEPTOR PLANCHECKFEE.
❑Ccriied copy b filed with the city inspection division.
CERTIFICATEOFEXEMPFIONFROMWORKERS' CREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1'. Date RCCCI IN
(1'hisardion need not he completed if the permit is for one hundred dollars
($I00)orlessJ WATER HEATERW/VENT/ELECTR .� ENERGY FEE Y N
I certify that In the performance of the work(orwch thinr
pemit la based,
I shall not employ any person In any manner w as to become sub)ect to the WATER SYSTFAI/TRGTING
Workers Compensation Laws of Ci llfomb.Date PAID
O Applicant - Dote Recei IN
2camof NEW RESIDENTIAL PLMB. SQFT.
Z O NOTICETOAPPLped tote after nskiomperthis.tion provisions
Exemption,you -
CC N should you
=at forthwith
with co Workers'such provisions
n pmvhis per it s Labbe TOTAL:
Code,you resat fpdhwlth comply with such provisions orthb permit shall be �_
� 9- ' deemed revoked. BUILDING FEE
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a O Iherebyaftlrmthat there bacomtmctlon lending agency for the perform ELECTRIC FEE
7 Z anceof theworkforwhtch this permit b iaered(Sec.3097,CIv.C.) _ TOTAL: ' LG
(� O Landae.Name PLUMBING FEE War
LL f- Lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U lmdifythatlMvercadthbappllotionaMAatethattheaboveinfor tion
O W. Lscorred.I dgmatocomplywith allcityand countymcitnancesand state laws PERMIT ISSUANCE _ FEES PAID:
} C relating to building construction,and hereby authorize representatives of this
[— Z city to enter u Pon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. DatC - RCGCipt#
(We)agree to save,indemnify an d krep harmless the City of Cupertino
V against liabilities,jodgments,coitsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
sgalnstsald City in< ence of the ammg of thin permit CONSTRUCTION TAX
__ AIR HANDLING UNIT(OVER tO,OW CI•11)
'Ignatureof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI LOSURE
Willtheappllcant or future building occupant store or handle haiardous HEATING UNIT CIO 100,000 BTU) Date Recei tit
material a.defined by the Cupertino Municipal Code,Chapter 9.12,and the
(Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Yrs [n No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) IM05--
$ DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? B0ILER-COMP(3HPOR 1(X,010 BTU)
4YnNo 1)E 0 9 u
havercadthe b.9usmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) ,
the Califemla Health A Safety Code,Sections 25505,25533 and 2534. I - •�
understand that if the building does not currently have a tenant,that itbmy NEW.RESIDENTIAL MECH.—SQ.-7. AIL. ,
respomibility to notify the occupant of the requirements which most be met we Of
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Data ISSUEU BY:
TOTAL:
OFFICE COPY