21060 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project Identification. - ruuDT NO.
Build r,gA�/ � Y 1 OV�n1
O .r'
7adz: _one: .' A
CITY OF CUPERTINO-BUILDING DIVISION
AML codtra! `'Z,*,,, APPLICATION / PERMIT l --cr-qjo
Archlect/Gglheer: Lld.No: BUILDING-ELECTRICAlMUMBING-MECFIAMCAL CANE-CORY CONTROL a
' CTRI BUILDING,PERMIT INFO
Q Y l .l! ELECTRIC FERMI F, .I" ' 't,FEE
Address: PERMIT ISSUANCE ❑ .. ❑. . -❑.+ .�
LIC ENS EDCONTR under ACTOR'S DECLARATION
lhereby[o.70'hat licensed ods,and my APPLIANCFSRESIDENTIAL JOB DPSCRII'fION
ingwlth Sedlon700f1)of Divlslon3o(t 'Buelnceaand Pmlesslana Code,and my -
license islnfu{•�IoryY�ddteR. ; J. PANELS
LicenseUP TO 200 AhMq
e`i.'lLLic.q (1," _ vxYr
Date C.n/TE I _
ARCHITECTED RAT OVER 1000 0ZO Iundentand my pbtu slug he used as public records OVER 1000 AMPS "'� SQ,FT'.FLOOR AREA 5/SQ.FT'.
E� Licensed Professional - - - SICNSELECT'RICAL
GG 6 OWNER-BUILDER DECLARATION
I`n SPECL3LCE2CUIT/hi -'
Ihercbmam
ya(Brthat lexemptfromthe Contractor'aLicenae Law for the
O 9q fallowing reason(Section 7031.5,Business and Protestations Code:Any city or -
,p �y , county which requires a permit to construct,alter,improve,demolish,or repair TEMP.METEROR EINST.- .
qq y�ygpQ❑❑ anystmu mpdortolb issuamc a6 mquireatheapplimnt forsuch permitto ro4VER DEVIC
K F 6 file a signed statement that he b licensed pursuant to the provisions of the
3c` Contractors License Law(Chaptsr9(co.mingwltti Section 7000).!Dlvl- VALUATION
ti O<�' skm3 ofthe Business and Pro(estom Cale)orthat he b exempt therefromand SWIMMI LEhECTRIC_
5 the basis for the alleged exemption..Any violation of Section 7131,5 by any
applicant for a permit subjedsthe applicant to a civll pemltyofnot nnrethan O SWIT Iq%'ITJ$FS
five hundred dollars($500). W RESIDENTIA EL E -7R v // 11,,tt
�I,as owner ll the property,or my employees with
.rded.a there sole .- �' ` •1 I\ STORIES .TYPE CONSTRUCTION
C e- c pec7044,willdo Businethework.Profeselo a Codet TheCtlntended orcense d for
Lw
55 q sale(See appy to Business owner
of property
hob:The or Improves
Limine LawV4—
does
Y
docsnot apply torn owner ofproperty whonlidsorimprovesthereon,add ' OCC,GROUP RES.UNITS
who does msuch work
eenotlhimself or relorough hisownem ployees,provided that such
impmvementsarenotintIrmayr..f, (orsal,t,, wevegthebulldingor '^ r AI,; '
Improvement bsold wltMnoneyearofcomplMlontheownsr-buRderwlll have .
t burden of proving that he did nat build or Improve for purpose of sale.). O'Iy„I,,q +i.ITLUMBINC ERMIT, ..'FGF',r' FLOOD ZONE nrN
ElL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
., rontradors to construct the project(Sec.70K Business and Professions Code:The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon, and who contractsforsuch ppojeda with a t
M
et.d.)hormed pursuant to the Contractors License Law. 'I"FEE SUMMARY'
L]I am exempt under Sec. B k P,C for this reason BACK FLOW PROT'Ff_T.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N .
• Owner - Dale - RECFFFT'p
'r..�/rfk WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL FAX Y_ N
• fi hereby orkers that I have a certificate of consent to self-tnsure,ora RECm'T a j
I,Lab Cle .Worketi Compevatlon lnsun^�nm opra certified�ropppy��thercof(Sec. GAS EA.SYSTEM.1 INCA OUTLET'S
3800,Lab C.)' d Z--i�GP Z�d�'/�y PARK FTE RECITPTT p
r.ury a GAS EA.SYSTGM.OVER p(EA)Com adv dcopy a.✓L - Bmf.Owc Drvlslory FEES -
Cedifiedcopy----�st hereby with furnished.
ecity GREASE/INDUSCRL WASTEI EPTOR PLANCHECKFEE
edified copy b(fled with the city Inspection division,
CERTIFICATE OF ECSMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- FA.200FT'. -Date Remi t# '
(This section need nes McomplMed if the permiHaforone hundred dollars .,.
(3100)mIces.) - - WATER HEATER /VFM/ELECTR ENERGYFEE 'Y_ N_
I certify that In the performance olthe work forwhlch this permit Is issued,
1 aha 11 not employ any person In any manner so as to heroine subject to the WATEIp BY /TREATING
O AWorlkea^Compensationlawe of Cahfornb.Date PAID
Z O NOnCETOAPPLICAN '.1Laftermakingthls Certlfimtenf F.xemption,you NEWR� ENTIALPLMB. SQ.FC. ^ Date Reeel t#
should become subject to the Work<n'Compermatlon provlsbw otthe Labor TOTAL:
T'0 Code,you must forthwith comply with such providom orthis perretahall be
W-j deemed revoked. - - UI •E
CL. CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby al0rrn that there is a rommacdon lending agency for the perform- ELECTRIC FEE
O ance.fthe work lorwhichthb permit is Issued(Sec.3097,Clv.C.) TOTAL: ELECTRIC EEE
V lender's Name - - , ,
LL I— Lenders Address QTY.. , '„MECHANI_CAL PERMIT', " 'FEE MECHANICAL FEE
OW Icertilythzt I have readthisapplicatlonand statethattheabovelnformatlon -
1 iscormd.I agresto comply with all dtyand countyordlnancesand Mate laws PERMIT ISSUANCE Zs� FEES PAID:
} N relating to building constructed,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for impectlon Purposes._ ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep hardness the City of Gu pertim, Date Receipt#
V against 'bilitlea,judgmenb,coatsand expenses iChmaym..yway.dmr AIRHANDLINCUNE E'010,000CFM) SUBTOTAL:
a aunt iq i in con uence of the an117. l�tyle rmlt.
AIR HANDLING UNIT(OVER iooao CFM) CONSTRUCTION TAX .
Signature of Applicant/Contractor 1 tSaY IXHAUST HOOD(W/D[ICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturebulldingoccupant store or handle hazardous , HEATING UNIT(TO 100,000 BTU) a Date CI t#
material as deB ned by the Cupertino Munldpa l Code,Chapter 9.17;and the
I lealth and Safety Code Sectlon75537(a)7 HEATING UNIT(OVER 100,Ofp BTU)
❑Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) IISSgANC)E
which enut hazardous air contaminants as defined by the Bay Area Air
Qu lity Management District? - MOILER-COMP OFR'OR 100,11(3 BTU)
•' 1Yes rcad then Nor
mrequimmChapterof BOILER-COMP(OVCR 100,000 BTU)
thehela Health&Safety Code,Sections,
e rre05,2553and,Shap.1
understandthatilthe6ildingdoes not currently havesemnq
-
that it is my NEW RESIDENTIAL MEIN.' SQ.Ff.
responsibility to notify the occupant o(Ihe requirements which must be met '
prlorto issuance daCertiflate ofOnupancy.
Owner or authorized agent Date ISSUEDBY:
TOTAL:
OFFICE COPY