21500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ;
Building Praiser Identl(latlan' PERMIT NO.
Building Address:
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Phone
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�9ns/vYYI CITY OP CUPERTINOBUILDINGDMSION ` p7)APPLICATION A
C°^oadgr."•
Lie.N. APPLICATION /PERMIT
.7. G .._ BUILDINGELECTRICALPLUMBING MECHANICAL CA'IRGORY CONTROL#
himet Engineer. Lic.No.
','.;O BUILDING PERMIT INFO'. "•
'QTY . ",ELECTRIC PERMIT .FEE
Address: PERMIT ISSUANCE •❑. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affimethat 1 am 11censed under provisions of Chapter9(rommene. APPLIANCES.RESIDENTIAL JOB DESCRIPTION
Ingwith Sa on7W0)ofai slon3ofthe Bupnessand Pmfesslon.Code,andmy
Ilcenx is In full .na afe;t g', •T ^ O PANES
Llansc Clam ' Llc.p
Data 6 Contracmr/274Z&C O L1+
.. ARCHITECI`S DECLARATION + 201-1000 AMPS L+
07 O (understand my plamshalbe used as publcrecords. OVER 1000 AMPS SQ.FT.FLOOR ARFA $/SQ.FT.
q
Licenmtl Pmfcmlonal '- ' SIGNSELECTRICAL
< ° OWNER-BUILDER DECLARATION SPECIAL CIl2CUfT/MCMC
7 7 hereby afR mthatlam exemptfrom the Contractor'.License law for the
following reason.(Section IMI
2— MIS,Business and Professions Code:An d or
county which requires a permit to construMalta,improve,demolish,or repair TFMP.METER ORPOLEINST. '
g'ygJp anystru"ure prior to its Issuance,also requlrestheappilcantforsuch permit to
15 O 0.F. file a signed statement that he Is Ilansed pursuant to the provisions of the POWER DEVICES
�0N sim3fthe License law(Chaptera Ccemencing exempt
SWIMMING POOL ELECTRIC
OS slon3e(lhc Bueinemand Profembru Code)orthat hebexempt theretromand - VALUATION
the bash for the alleged exemption. Any violation of Section 7Mby any
' p
applicant for a permit subjects the applicant to a civil penalty a matt. than OUTLETSSW[TCFiESFI /`)��
�G five hundred dollars($500). - V
7a DENTIAL E�I,act owner of property,or my employes NEW R with wages as their sole c"Q'hTSTORIES 7YI'E CONBIRIJCTION
solcompensation,wul dotbe wot$and the s C dere&sea Intended or offered for
$ O
does net70K
malneasandf presslomhobudihe CompactorsLJmmxvthemon law
doanot applytoan ownelfcrth ghhis wnemsoyers,p vnthereoryand ` OCC.GROIIP RES.UMTS
whodoesard...khimselfedorough hisow formic.
If,however,
thedthatsuch
Improvement.arenot Intended earofco plea .If,howaeg ildbr l It -or TOTAL:
Improvement proving
within he did et build
Improve
for purpose
a ve
ths�arden of proving Mat he did not build orimprove for purpbae of ale. QT'y, P MB GPBR IT' FEE''' PIAODZONE APN
"L as owner of the property,am exclusively contracting with II se p UA CE
contractors to corulmot the project(Sec.7044.Business and Professions
T1s Contractors License Law does not apply to an owner of property o A „ -DRAIN& - ATFR[FA)
Wilds or improve thereon, and who contracts !a such pkojeds with
cgn[Ia"orUl li...cIp6nuanttothe Contractor's License Law. .- FEE SUMMARYt;
LJ 3'.m exempt under Ser. B& P C for this reason' B CKFLOW PROTECT.D I
Owner Date
DRAINS FIA ROOF, SANITARY Y_ N
- RECEIPT#
WORK MAN COMPENSATION DECLARATION
rgFIXTURES PER SCHOOL TAX Y_ N
�hereby affirm that I have•artiflcate of consent to self-loam, FIXTURES-
RECFFPf# .
art[flate of Worker's Comperuatl°nlruu anaoracertlflM mpythemof(See. GAS[A. .4 ETS PARK FFR Y N
J800,lab CJ / •� �7
IPoligp rn �L ,.i / - RECEIPT#
Com GAS EA.SY .O E 4(EA)
' Y 9 BE]L DING DI VI SION FE:ES
Certified copy V hereby furnished. CREASE/INDUSTRL tSTRINTERCEPTOR PLANCFIECK PEE
=Tiled ropy b filed with the city bupectlon dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
rdU
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date RCcel t# '
(Thlseedian need na be completed lithe permit k(oror�e hundred dollars
.($l IcelemJ-
]arti(ylhat the perlormana of the work lorwhich this permit Is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
1 shall net employ any person in any manner sou to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date . PAID
O Z ApplicaNOTICE
OTICE TO NEW RESIDENTIAL PIM B. SQFT. Date RM'el t#
ZO NOTICEcome subject
to the
orkersk Compng ensation
Certnlateo(Exs of the ,you
ahw,you mus.forth forthwith
co ply wit'Cumprovitins orchis per it s Labbe TOTAL:
or
L N. Code,youcomply with such proWlom orchis permit be w!�
deemed revoked. - BUILDING �•E LW
CLG - CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affirm that there V a construction lending agency for the perform- ELECTRIC FEE
TOTAL:
Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) '
O O Lender's Name PLUMBING FEE
IL I— Lender.Address QTY MECHANICAL.PERMIT t FE6 ' MECHANICAL FEE
O W Icealfythat l have readthisappllcatlonand statethat theabove Information
4 acermd.I agra to comply with all city and county ordleanees and pate laws PERMITIESSUANCE FEES PAID:
�. W relating to bullding ronstrvdlon,anti hereby authorize rcpremniativca o(Ib - -
I— Z dtyteenterupon the abovo-mentioned property(or Wpectlon purposes, ALTCR ORADD7OMECH. Date RecCl t#
_ (We)agrcc to mvG Indemnify an d kap harmiem the Clty°f Cupertino - P
against 11 bill e,7adgme roatsand expenses which may In anywayaccrue AIR HANDLING UNIT(7010,000 CFM) SUBTOTAL•,'
agaivt.al tyln con ence of the granting of chi.permit.
AIR HANDLING UNIT(DYER 10,000Cm) CONSTRUCTION TAX
Slgex4rd.f Applicant/Contractor Data EXHAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(10 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date Recel t#
I filth and Safety Cade ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (,
M, Yes ENO, _
Will the applicant or future buddingoompant use equiprrent ordevices VENTILATION FAN(SINGLE READ) ISSU(kN . DATE
which emit haurdoua air contaminants as defined by the Bay Area Air - 00
Quality Mmagemenl Dist BOTLFR-COMP QHPOR 100,000 BTU) Y
❑ Yes I f�(Ngo7
Ihavc rcad[he hazarTZrnatcdale mquirements under Chapter 6.95 of BOILER-COMP(OVER 100,D00 BTU) Nov
theblfernla Health&Safety CWx,Sectbns25SR5,25533 and 255X. 1 �(
undersUndthat if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. ,
rusporeib' tonal eompant of the requlrcmenb whkh must be mM
p=ort nceo r'tlflatecd Occupancy. AgiC4s� "�
ur autIrrized agent Date
• '• TOTAL: ISSUED OYaWe�h � -
OFFICE COPY