21740 APPLLCANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PEL59TNO.
Building Add rev: LOY 3v� �h,� 21740
Q.T (in Q t- _
ars one: A p
CITY OF CUPERTINO-BUILDING DIVISION
'rN
tratt r,N4A. Lie.No: APPLICATION / PERMIT
A h¢ec/ L IaBMLDINGELECTWCAGI4d)MBING-MECFUNICAL CATEGORY CONTROL0
/. QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrm that lam Bcenxdunder provhbnaef Chapter 9(co., APPLIANCESRESIDENIAL ]OB DFSCRDTION
Ingwlth Scclon 7000)of Divlalan3ofthe Busisirc a.dd�Pmffe ...Cnde,and my
licervao
llinfu
df d
LlcensaiClass 11 fonyandLle.N '�/ L l/ ;z PANELS
Date —'.I/j•—Contractor l''
ARCHITECTS DECLARATION 201-1ODO AMT'S
�7 I understand my plana.hall be used u public reconls OVERIOODAMPS SQ.FT.FLOOR AREA f/SQ.FF.
O /
d0 - Licensed Professional _SIGNS ELECTRICAL /,I IS /_1_
7 6 hat].exemptf r DECLARATION SPECIALCIRCU1T/MISC �c�'�� /IT (�^ r
0 , owinz'qg raf@mtkton7emmpttromthc Cant racari License Law for the -_IY7 K
O, following reason. 7m1.5,Buslnesaaral Profession.Code:Any cityor
FM9. mntywhlchmqubeaaper t..r tw ,alter,Improve,dennlish,ormpair P'MEIFR ORPOLE INS?.
gggYY '< any.tmdum priorto Its lnxuanee,also requires theappllemt forsuch permit to POWER DEVICES
C U Ole a speed statement that he b handed pursuant b the prow ices of the
Ow Contractors License Law(Chapter9(ce—reing with Section 7000)of Divi-
05 VALUATION slan3o(iheBwinesand Pmfessloes Code)orahat hels eumpt thercfromard SWIMMING POOL ELECTRIC
the Wall,for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWIICHES-FIXTURFFS (- L 1
applicant for a Parma subjects the applicant to a civil perulty d na renrc than
c O five hundred dol loft he pr). STORIES ECONSIR(CTION'
'9..' ❑I,st owner llotework aorhe employeswith wage a.their sole NEWRESIDENTIALELF
k 7 a .]a&compesai0Kfhafte..ew Peru.nd hes Code:Th not Intended o icenseoffered forw
$` ❑ vie&c.70K to..
property Code:The Contractorshecao Law
$$ don oessucytork owl dpmperthiso buimporimpewvided roNand OCC.GROUP RES UNITS
whodoementawork tboarl arthrough ed awns.If,ho s,antes dthat such
' ImproverrcnU arc not Intended oroffertdfa sale.If,however,thebulldinga T T
Improvement issold within oncycarofcompletiogthc owner-buOderw111 have
[burden of proving that he did not build or improve for purpose of sale.). QTy, PL M FLODD ZANE APN
LJ I,as at of the Property,am exclusively mntracTing with Ilansd LgUANCE
Grob actor 10 construct the project(Sec.7064 Business and Professbm Code:
The Contracori License Law don not apply to an owner of property who ALTER-DRAIN VENT-WATER(EAI
builds or Impewes thereon,and who contracts for such plopcs with a
�gat�a0or(a)li¢nsed pursuant to the Contractor.License Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
L_J I am exempt under Sec B Q P C for thio rcaaon
• Owner Date DRAINS FLOOR,ROOF,ARCA,GOND. SANITARY Y N_
RECm l'N
WORKMAN COMPENSATION DECLARATION FDnIJRES.PER TRAP SCIi00L TAX Y_ N
❑1 hereby orDem that I have a I n mnc of Consent m self-insure,ora RECEPF N
mm'Lateo(Worken'Compeesatlonlesuran<e ora reified ropy thereof pec. GAS EA.SYSTEM-11NCA OUTLETS PAR Y N
RECE3BW,1�6 C.)
i'oliry N GAS EA.SYSTEM-OVER l(TAI DING DI N
Com Env �a< rl t0 Pk+4.�.. BUILDING DI VIBIONFEGS
[�CemBed copy i.fiedwithrthe city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�Ccrtilied ropy u tiled with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANEAAYSIORM EA 200F7 Date RCtt'f t# S
(This section need not be Completed tithe permit It forces hundraddollars
(5100)¢fess.) WATFRHEATERW/VENT/EECTR ENERGY FEE Y N
I mnM that Inthe ppe performance o/thework
wmiabthis permitbjla Issued,
1 shale not employ any person in any runner w v to become subjett ao the WATER SYSTEM/]BEATING
Worken'Compenmtbn hws of Califarnla. Date PAID
O Z Applicant NEW RESIDENTIAL TOMB. Date RCIX'1 taY
F
Z 0 NOTICE TO APPLICANT:]LaRer making this Cerbflcaleof Exemption,you
should become subyeet to the Workers'Compensation provinces of the Labor TOTAL:
jr W Code,you=at forthwith comply with such provlsleu or this permit shall be
> daemed revoked. BUILDING FEE 517J, 0
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that tkrc V a mestmclan lending agssy for tk pcsiorm ELECTRIC FEE
� Z nceofthe workforwhich thio Perrot ls(vvM(Sec.3097,Civ.CJ TOTAL:
U O 1<nderb Name / / • PLUMBING FEE
LL 1— Lender.Add... �' / QTY. MECHANICAL PERMIT FEE MECHANICAL FEE /
O W Imrtlfythatl have mad this appli tion and statethat thealorwinform.lion
1 bmrrttt.l.grm to complywlth alletyabyauthyordinanmand Asia laws PERMIT ISSUANCE FEES
} N citytaiutIant rupongmrbtrudion,and coned p operty ori lex representatives npurpos of thB 1 (l 66H5/
F Z cltybenteree to saw,he
an
property for Wpe Cit of Cupes.ertino
ALTER OR ADD 70 MECH. ate Recei tN
V — (We)agree to save,indemnity an d keep which the City of Cupertino P
agaWtliabi1111n,n con b,c�.and expenses wbkh may ln any wayamue AIR}iANDLING UNIT(FO 10,000 CPM)
agaiestaaidlCity In cons¢ryen¢ the gloating.(this permit SUBTOTAL:
�4/ AIR HANDLING UNIT(OVER 10,000C II) CONSTRUCTION TAX
Signature of Aa t/Contractor 7 late F ExHAU5TIIO0D(W/DICT) CONST CC[ON TAX PAID:
HAZARDDUSMATERIALS SCLOSURE LI14t (jjl���
Willtheapplicmnt or future building cccvp tstoreorhandlehaaandous HFATINGUMT(TO 100,OIOBTId) �—t Date RCCei tM
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Ilealthann Sedion25532(a)? EIEATING UNIT lW,00B BTM Safety CodTOTAL' ^ !7
❑ Ys M No
Will the applicant or future.building occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardous air contaminanb as defined by tic Bay Area Air L
Iity Management District? MOILER-COMP OIIPOR 100,000 BTU) S
�Y Yrs. ❑uo S
]h'wreadthehuarda .rtutcriab mqulrementa underCkpter 6.95 o! BOILER-NMP(OVER I OO,000 BTU)
the Californialiealthh SafCty Code,Scdioes2SM5,25573and255U. I p 7
understand that if the building don not currently have a tenant,that it is my NTWRESIDFNIIALME4-I. SQFI'. FES 1 x9.7'10(}
1
re,ponsibility to notify the occupant of the requirements which must be rrct
potato Issuance ofaCartifcateofo
Owner oris h�dd a• gent Date
TOTAL: ISSUED BY:
OFFICE COPY