21892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building ofd , D ,'. 21892
Coo e a - I one: CITY OF CUPERTINO-BUILDING DIVISION
No APPLICATION / PERMIT
Ko BUILDINGaECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL M
Arch tett/Engineer. Lic.No:
QTYELECTRIC PERMIT .'' FEE i BUILDING PERMIT INFO
Addrcas: PERh9TISSUAN \� ❑ ❑ ❑
LICENSED CONTR under rDECLARATION
I hereby affff$(($yj��rmmmtJ�a{{alost. edhelhudross.rdsonCaskuni 9(commmc- APPLIANC D L OB DESCRR4ION
Ingwlthtin efelon3ofthe BuslnessandPro(essionsCode,and my
license le In offset. n//'3 /} PANELS
License Gla I /
Date ContndorTOROAZ
ARCHITECT'S DECLARATION 201-100
rs0 O I understand my plans shall be used 'a public records. OV 1 PS �f'. y/SQ.F7.
Licensed Professional G EL L
6 LGy3 OWNER-BUILDER DECLARATIONC UAIgG M P U T E
z g Iherebyalflrmthat Iam exempt from the Contractors License Law for the
following reason.(Section 70115,Business and Professions Code:Any city or
Ft' countywhich requinesa permit tororotrod,alter,improve,demolish,arrep POLE WSF.
anystmmmphdortolM1bwance,al mquimstheappllantiorauch perMt
flit a sed statement that he Is Intr and pursuant to the provisions of th ES
3w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- r POOL FLECTRIC
,,SOS sion3 of the Business and Pmfosloru Code)orthat he is exempttherelrone and --'VALUATION
the basis for the alleged exemption. Any violation of Section 70)1.5 by any
<
applicant tore permit subjects the applicant too dvil penalty of not more than O SWITCHESFIXTIIRES
fiFe 1,as ed owner of
he pr. R DENIAL ELECTR .FC. 5 RIES TYPE CONSTRUCTION
z< c m I,as owner of the property,or my employees with wages as their sole
pee.704n,B..inestarat kandthestruGurebna intended or exca; (or '1�L/�} 1
D doe(Sec.apply
to an ow and f property
rope ty Code:The C Improvre Liman Iaw (�
($5$ does not
essuchtoan owner ofofprough hison emoyce,provided
and such OCC.CROUP RFS.UNITS
whodoes
set am not
hinted edorofghhbowne.If,ho ea,however,(he
building
or
improvemenh sonotinlendcd earcdco forsak.the
hoverer,theerwiH have TOTAL: I�,L
Improvement V wld withinoneyearofcompldloM the ownerbullderwlll have
the burden of proofing that he did not build or Improve for purpose ofsak). QTY,I PLUMBING PERMIT FEE FLOOD ZONE APN
0 L as owner of the property,am exclusively..ratting with licensed PERMIT ISSUANCE
contractors to omstruct the project(Sec.7044,Business and Professions Code:
The Contractor's License lAw does not apply to an owner of property who ALTS-DRAW AVENT-VENT-WATER(EA)
builds or Improves thereon,and who contracts for such inpOets with a
"bactor(s)luresed pursuanttothe Contactors Llearse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec. B fit P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
•' Owner Dates
COMPaTJ5AT10N DECLARATION RECIDrr0
FE)n URES PER TRAP SCISOOLTAX Y N
la i hereby affiren I have o ceelficate
franc of consent to self-insure,(S a RECEIPf M
3800 crab o(Worken'Compemattonlruurance oraartifled ropythereof(Sec' GAS EA.SYSTEM-I INCA B
3800,Lab C. � PARK FT]5 Y N
Policy tl� DING OF p
Com n rEA.SYM'B4-OVZ$;fEA)-OV )Y BUILDING DI VISION FLIiS
Cert ie copy b herebyth th ofd. ASTE IN'1'Q(CEPTOR PLANCHECK FEE
Certified copy V filed with the city Irspedian division.CERTIFICATE OF UEMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE -b7ORM EA 20047. Date Recei t(Ehlaeectlonneednot be completed It the pemdt V farone hundred dollars ondfly /VENT/ELECTR ENERGY FEE Y N
I certifythat In the performance oftho work(or which 1M,permit b owed, —
I shall not employ any person In any mannerso asto become subject totheRPATING
Workers'Compensation Lawsof California.Date PAID
0 Z Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Re t#
Z O NO37CET0 APPLiCAMheWorkemaking
omputhis Cardilate of Exemthela you
o
Code,shoulyou
fort withd to co ply will
pme,cs mth ov o elt shall
TOT L:
� W Code,you nwat(orthwith comply with such proWslars orthls permit shall be B WC '
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyatflrm thattherelsa mustrunion lending agency for the perform- ELECTRIC FEE
Z ae..fthe workforwhichthispermit Is bsued(Sec.M97,Ce,.C.) TOTAL: L
(,) O ]ender'.Name�}—� PLUMBING FEE
LL F I.radars Address ` ++ QTY. MECHANICAL PERMIT F'GE MECHANICAL FEE
O W ImdifythatlhavereadtMsapp11at1anandk.wthattheabove Information
bco ed.lagreetocomplywlth all city and county onllnancesand datelaws PERMIT ISSUANCE FEES PAID:
�. 1 relating tobulldlegoonsbudlon,and hereby authorlse representatives of this
F N citytoenterupon the abovenrxmlonsd property for hapection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receip#
V against liabilities,judgments,cousand expenses which may in anywayacave AIR HANDLING UNIT(170 la," SUBTOT L'
agalnet said City In consequence of the granting of this permit.
AIR HANDLING UNV&VER JAMM) ONSTRUCTION TAX
Slgwturc of Appilant/Contractor Date EXHAUSTHOOD CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant o future building occupantsom,or handle hazardous HEATING T(TO100,0001111J) Date RCCCI t#
material as defined by the Cupertino Munidpal Code,Chapter 9.12,and the
lkc lthand Safely Cods, 9ion2S532(a)? HG 'G UNIT(OVER 100,01)BTU) TOT L:
❑ Yea a��(No
Wllllheapplicant urcbuilding ocmpantuee equlprrent ordericea 'RLATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air -
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU)
4Y. MNo
have readlealth the ar et materiaercons 25055533 and
of BOILER-COMP(OVER 100,000 BTU) SEN
the California Healthk Safety Code,Sections 25505,25533 and 25536. 1 snQ �
understand that thebullding dos not currently have a tenant,th tItes NEW RESIDENTIAL MECH. SQ.17. A 7(� 7
roporeiblli ythe occupant oft Ircme which at be t ?5,` 6
prior to lss aCertificateuf cy.` n(
Osv uthorl,rda �/l
Date ISSUED BYE 1 VC«'AtS�1l.Ta�"`a—"
TOTAL:
OFFICE COPY