20950APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
.
Building Project Identification -
RuBdtng Address:
-rorrvenue;
Teem � A
PERMITNO.
20950
nersams: one:
44Zlea � / 74-
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CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
BIIILDMGELECTRICALPLUMBINC-h(EC LAICAL
-30^20
contra .Name: (/���y�G Lic.No:
Q,1 �/4.`l"'�•
CATEGORY
CONTROL p/Iqf
VO C�
It /Engmeer, / r / i /I— ; / 6
��ffj
Il L
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
San 1=qk7VPLUM6o
react: -n I I nsz•,
PERNITISSUANCE
,. ❑ ❑ ❑
LICENSED CONTRA OR'S DECLARATION
I hereby affon that l am licensed under provisions of Chapier9(commmc-
Ingwith Section 7000) of Dlvldon 3 ofthe Buslnessand Pro(essionsCode, and my
license 1s in full fora and effect.
Llan. Cl Lk.p
APPUANCESRESIDENTIAL
PANELS
JOB DESCRBa]TON
TT`I.
��l••``
DateContractorUP
TO 200 A
201-1000 AMPS AAI
ARCHITE SDE TION
I ret5nd used public eroods.
Licensed 7ste sional
OVER1010AMPS
SQ. FI. FLOOR AREA
`TT Y1
$/SQ.Fr.
SIGNS ELECTRICA
OWNER -BUILDER DECLARATION
I hereby atfirenthat I amexempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
muntywhich requires a permit m mnstrud, alter, improve, demolish, or repair
any.truclure prior wits issuance, also requires the applicant for such permit to
file a signed statement that he is b
licensed pursuant to the provisv of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dist.
slon3oftheBusmessandProfessionsCode) orthat he la exempt therefeamand
the basis for the alleged exemption. Any violation of Section 703 S'by any
applicant fora permit subjects the applicant to a civil penaltyed not more Its
dollar).
five 1, as demo the
I, as owner of the property, or employees with wages their dole
'
SPECL1LCBiCUIT/MI
TEMP M OR NST.
TOWER CES
G EI-
OIA7. 7C[ -&SFT
NEW D EL
VALUATION
9Q j
t l')
STORIES
TYPE CONSTRUCTION
compensation, wW Bothe work, andihea
ue reh not intended or for
sale (Sec. Code:License
Code:The.rimpoweContractors License law
L
toBusiness
wand f pooptty
an owner
does notwhodea such orkht n if (th ghhis o WIld.nemplc ees p idedthn,and
apply
whodoementsa not intended
hrwgh hlsowne. If,ho es,p however,
thatsnor
Improvementsarenotintendedprofferedforsale.ILh ner-q Hder ldmgor
improvementladoldwithin oreildnot cuildoron,shee for purpose
rpose ofsalove
t rdeno(pro of the theerty,a build orlmproveforpurpoaaf.ane
Mtn owner of the properly, am.exclusively Busi contracting with Ilan.d
Code:
Business and of property
The Contractor's loopm Llan a La, and not apply tct an owner of Property who
TheconContra to construct the w. ed (Sec. apply
Wilds t r improve. thereon, and who mntnde for each ptojeda with a
cga(lacmr(s)Ilan.d pursuant to the Contractor's License Law.
LI I am exempt under Sec. B k P C for this reason
pL;
QTY, PLUMBING PERMIT FEE
OCC.GROUP
RFS. UMTS
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER -DRAIN A VENT- WATER MA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FD(TURFS PER TRAP
SANITARY Y_ N_
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION
�I hereby affirm that 1 have cemfiale of consent to thereo
SCHOOL TAX Y N
ora
o
certificate otWorkers'Comperuatlonlwurance oraartlfied ropythereof(Sec.
copy
3plic Lab C.)
RECEIPT M
GAS EA. SYSTEM -1 INC.4 OUTLETS
PARK FEE Y N
Polity p
p
RECEDING
any
CoKCettified
GAS EA. SYS[EM-OVERd(FA)
DI
BUILDING DIVISION FEES
ed
copy la hereby ramie city
t71 Certified copy Lc filed with the city inspection division.
'W
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CERTIFICATE OF EXEPTION FROM WORKERS'
�j �,a�J� f; /`
PAIDI Jae W ��–+11
CR�E�P
COMPENSATION INSURANCESEWER-SANITARY-STORM
Qhissection need not W completed Rthe permit later one hundred dollam
($]00)aleseJ
(certify ehat employan person
I shall not employ any person in any manner m u to become subjed to the
any cone ork fa as I. became
eesubjec tothe
Workcrs'Compensatlon Laws of California. Date
NOTApplTCEt
NOTICE come APPLICANT: e after making pe ation pro is ons oftExempthe
s Lobar
sode,yohould mustfrthwitect the Workers' such prvisinporthis permit
Cade,youmuetforthwlth comply with such provlaloru orthla pertNt.hallbe
d
domed ..ked.
CONSTRUCTION LENDING AGENCY
(hereby affirm that there is a ronstmctmn)endingagenry for the perform
ance of the work for which this permit is h sled (Sec. 3097, Civ. Q
Date Recei t#
7r1
EA 200Fr.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
rr _
Q a* (6 "57 6
PAID �a� ( 7
Date Recei t#
.
/'`r--.,
7 rO yt
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLM3. SQFI'.'
TOTAL:
BUILDING FE .
TOTAL:
SEISMIC FEE
d
I
ELECTRICFEE
Lender's Nacre
Lender'. Address
I certllythatI havereadthis application and statethatthe above Information
Iscorred.I agree to comply with all city and county mdmanceaand state law.
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
'
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:,
relating to building conetrodion, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemNfy an d kap harmlem the City of Cupertino
again 11 bill e, rydgments,coslsandexpenwswhlchmaylnanywayacme
aid Inco equence o(the gra ntingoftMspennit.
ALTERORADDTOMECH.
MR ]{ANDLING UNIT (f010,000 CFM)
Dale Recei t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER ]O,ODOCFM)
CONSTRUCTION TAX
Sgnaturea(Applia /Contrador Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA4AROOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU) `
Will the applicant orfmm building occupant store or handle hazardous
material as defined by the Cupertino MuNcipa) Code, Chapter 9.12, and the
Date '' ReCei I#
HEATING UNIT (OVER lffl," BTU)
TOTAL•
I Isalth and Safety Cade Section 25532(2)7
Q Ye. MN.
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
. Will the applicant or metre building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
ality m
Manageent Distridt
BOILER -COMP DHP OR 100,0(0 BTU)
Yee{ No
'
BOILER -COMP (OVER 100,00 BN)
haveread the haze o s als requirements under Chapter6.95 of
the Call(ornlaHealth &Safety Code, Seatimus 25505,75533and 75534.1
(r
NEW RESIDENTIAL MECYI. SQ.Fr.
understand that if the building does not currently have a tenant, that it is my
6• I A}
' —Portal yppppy(((1((IllIIIity to noilfy the occupant .f the requUemenb which most be met
prio ants a iateof Occupancy.
iiiiii �
ad.g
ISSUEDBY:
Owner or authorized ag t Date
TOTAL:
OFFICE COPY