21538 APPLICANT TOFILLIN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Idemmranon PERMIT NO.
Be1H�0�% ► Mt T� 21538
scot: one:
Jere aSs-67d'7 CITY OF CUPERTINO-BUILDING DIVISION
Co rayFt�o/{e Name: /y ��{I--( /��ry �.r .LISN[ry9- APPLICATION / PERMIT
'�`^ L aj ' '` a" -- - ^ 4 �—'-�•`� BUILDING-ELECTMCALPLUMBINGMWHAMCAL CATEGORY CONTROL p
ArcMled/Engineer Lic.Nex
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. I PFRM[TISSUANCE Z,16 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter9(mmmenc APPLIANCFSRESIDENIAL J BDESCRMTON
Ingwllh5'InZ0)0)car Dlviclon3of[hp Busi9paeand Pro(eealone Code,end my
license IB In def fed. ///_C PANQ 5
Llccnaac - 111 4
DaleContrador -
ARCHITECPSDECLARATION 1(11-IOM AMPS
ce0 O I understand my phu shag be and v public recorda, OVER 10DO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
bLicensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION {{��
I'n SPECIALCRCNT/MIST
Ihereby a(nnnthat lamexempt from the Contractor'sContractor'sLlcLicense „ C LAW fort hgg
Q following reason.(Section 7031.5,Business and Iarolesslons Cade:My dJy1Sr
,altegimprove,de=lR h,ormpalr TEMP.MECLROR POLE IN5f.
C cwnlywhkhmquimsapermittommtmd '
'� any strudum prim to its issuance,also requireatheapplicanl for such permit to
file a signed statement that he is licensed pursuant to the provisloru of the POWER DEVICES .
3w Contractors License Law(Chapter 9(rnmtrendngwith Section 7000)ofDivi.
I„�Og Q don3ofthe BusNmv dPro(eAomCode)orthathebexempttherefmmand SWU`Lh9NC POOL ELECTRIC VALUATION Y the basis for the alleged exemption. Any Violation of Section 70315 by anyOUTLETSSWI7CHESFlXTURES
appilant fora permit subjects the applicant to a dvil penalty of not morethan
rav,�ej�undrod dolhn($SM. NEW RESIDENTIAL ELECTR
�n euas owner of the property, �� SIORIES TYPE CONSTRUCTION
persp party,ur my employes with wage as thele sole
roc(Sec. 044,wtil do the Business awork and the om C durc V not Intended or coffered for
O ale(Sec.704y Business and Pro(esslov Code:The Contradole License law
3$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through his own employces,provided that such
Improvements are not intended oroffemd forsale.I(howewr,thebuildingor j TOTAL:
Improvement haold withinoneyvarofcompletiogtheowner-W RderwOI have
tilLjIordenofpmving that he dal not Wild or Improve(mpurposeorsak.). QTY. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD%DNE APN
PFRhtTf ISSUANCE
contractors to romtrud the projed(Sm 7016,Business arad Profemloro Code: IOZ,06
The Contractor's License law dm nor apply to an owner of property who ALTER-DRAIN 6:VENT WATER(EA)
Wilds or Improves thereon, and who contras for such ptojeds with e
c�fadoral licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this consent
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT M
WORKMAN COMPENSATION DECLARATION F0(TURES-PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to ulf-Inmm,or A-/� RECD,Y
S VV
380DnLabC)W�oIrk1en'Com tltlon7 �,T�a5n5yS oar a/ceJrtified spy thereof(Sec. I GAEA.SYSTEM-1 INCA OUTLETS as PTOFEE Y N
RECEIPT Y
Co
GAS EA.SYSTEM-OVER 4(FA)�anv BUILDING DI VISION F[ES
Gyd+nee ropy is rcby(urnbhed. CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
I�'Ccrtined spy Is erste nets lM dry inepMlon alviafnn.
/-' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SL- SANITARY-SANITARY-SCORN EA.300F1.. DRIC RCCCI 177
Qhiswction need not be completed If the permit is(m ore hundred dollen
(SIO mei le a.) WATER HEATER W/VENT/ELLCTR ENERGYFEE Y N
I cenorffy that In the person many he rework far which1hlspentylis Ito the —
I shag nm employ any person In any manner at u to become subject to the WATER SYSTEM/TREATIN'G
Workcre'Compenwtlon Tawe of California.Date PAID
licant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEN RISIDENTIALPLMB.__SQ.FT. Date Recel HI
Fshould become subject to the Workem'Compematlon providans of the Labor TOTAL:
N Code,you most forthwith comply With such provisions or this permltahall be
j deemed revoked. BUG •',
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
ZI hereby afOrmthat them Naconstruction lending agency for the perform, TOTAL ELECTRIC FEE -O
ance of the work for which this permit b tested(Sec.3097,Civ.C.) a O
02 Lander'.Name PLUMBING FEE
LL I- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cenitythatl haveread this applicalionand statethat theabove infornution
bromed.Ica rce to comply with alitlty and county orelnanres end state laws ' PERMTTISSUANCE ��.0 FEEIq: f
relatingto Idingrorutruction,andherebyauthorizerepresentativesofthis {(J///•�''/[�
H Z city to ent r Pon the abco -cmntioned property for Inspection purposes. ALTER OR ADDTO MECH.
(We) to ave,Indemnify an d keep harmless the Cl of Cupertino Bf Recti to
V agalstl b t dgmenb,rortaand expenss which ma yw yeast AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
age I i o eryu n of he granting of thisN
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrutureof Applicant/Contractor Dae D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or future building occupant atom or handle haaardoua F{EATING UNIT OO 101,000 BTO DBfe
material..defined by the Cupertino Municipal Code,Chapter 9.1 3,and the - Recef tN
I lcalth.ed Safety Code Section 25537(a)7 HEATING UNIT(OVER IOR000 BTU) TO
TAL.al
❑Yca No
Wllllhe applicant or ,.building occupant use equipment or devices VENHLATION FAN(SINGLE,RFSID) ISS�1UAJxJ,CE DA
Which emit haurdous air contaminant,as defined by the Bay Area Air 6'”(g
Quality Management District? BORER-COMP OHPOR 100,000 BTU) 13 �99'
4 Yca �No ,179
have madthebaa auamaterialsrequimmentsunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Glifornla Health A Safety Cod,SMlau 75505,15533 and 75SM.I
understand that if building dos not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. M1�h
responsibility to ndlfy the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy,
d �psa
Owner or authorlaed agent Date ISS
TOTAL: ZVI
OFFICE COPY