20306APPLICANT TO FILL IN INFORMATION WITHIN RED LINTES"TWINOWPOINT PEN ONLY
BuildInA Project Identification
Bund ing Add rem:
O/OU 7D E E I 06 Dl• f
PERMIT NO.
i'1 O ^ O 1�
G 3 6
wnereName: ane:
CITY OF CUPERTINO-BUILDING DMSION
APPLICATION / PERMIT
BURRING-ELECTRICALnL BIND- MECHANICAL
-
Ii
Csshactor'sName:
CATEGORY
CONTROL Y
Architect/Englrieer. Lic. No:
''QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add..
11�� fiL le
LJ L� leY
- PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter9(commenc
Ingwlth Seeion7OOD)of DiviYon3ofth.Buslnseand ProfeW...Codgandmy
Limee is In st form and effect.
If... Chm Uc.Y
Date Contractor
ARCHITECTS DECLARATION
I understand my pians shag be used a a public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I lomewing realms. a (hat on 7 31.5, B (romthe d Profetor'a sCodee law for the
following ichmq (Section 70315, Business and Pmfemb , Code: Any city it
anystmcmntyhmrequiresap antocostmrs,alter,improve,demolbh,orfdtto(O
anyasucture statementof t e
file t signed statement that het licensed pursuant it the pro 7000) of the
he is, alsorequlrcstuant to the provisions
Contractor's Licensemann (Clupter C dmencing th.th. h5ectlon .,tth0Wfo( .vl-
theblfo thealsend ProfmicsC nyviolati hob exempt therefrom and
the Wats for the alleged exemption. Any violation ofSectionby anyOUT1,R7
not
five hunt fora permit dred dollarsMbjectetheappilcanitoatlWl penalty o(nat moretha
(5500).
Ove 1, ..owner of
❑ 1, as owner of the property, or my employes with wages as their sole
compensation, (Sce.7KBuldess and work, Professions Code: The not
Connendedctor u License Board
mle(Scq 7034, Business and Pro(eaios Code: The Contrarsote Llcese law
Law
does not apply to sa owner of property who Wilda or Improves thereon,and
whodoessuchworkhimselforthnarghhieownemploym%providedthatmch
Improvements arc not Intended or offered for sale. If, however, the building or
Impmventbnidwlihinomyearofcompletion,lheowner-bugderwnl have
tFyjurden of proving that he did not build or improve for purpose of sale.).
Lf 1 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Success, ineand Pro(emias Code:
The Contractors License Iaw dos not apply to an owner of property who
Wilds or Improves thenen, and who contracts for such pkojects with a
coA�((wor(s) Banned pursuant to the Contractor's License Law.RACK
L ec I am exempt under SB k P C for this reason
APPLIANCES -RESIDENTIAL
BD RRMCT
e'� '�'1
%lam -x � 1�
-
PANELS
UP TO 200AMPS
201'1000 AMPS
OVER1000AMPS
SQ. FT. FLOOR AREA
sm. Fr.
.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M15C
TEMP.MEITR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
SWITCHES FIXTIR2ES
VALUATION
' �`O / /�
k Q(1 • v0
NEW RESIDENTIAL ELECTR SQ.FT,
STORIES-
TYPECONSTRUCTION
, /—Al
v
TOTAL;me
.
QTY -1 PLUMBING PERMIT FEE
OCC.GROIII'
/�
1 1,[ i �3
RES, UNITS
FOOD ZONE
APN
ppR�CE
ALTER -DRAIN k VENT •WATER (E.V
FEE SUMMARY
1ba
FLOW PROTECT. DEVICE -
OUTSIDE FEES
ROOF, AREA,
DRAINS- FLOOR A, O
_
SANITARY Y_ N_
RECEIPT a
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby still. that I have a certificate of consent to self -insure, ora
certificate of Workers Compenaatlonlsunnmaramrtifled mpythereo(�ec.
3800,LabCJIfi,
Poll Y
Fp(gU)(pS.PER TRAP i r t ,(
Sg1100`L'iTA% Y N
RECEIPT M
GAS EA. SYSI'FId-1 INCA OUTLET'S a
PARK FEE Y_ N
nn.a• ftE22K
I
GAS EA.SYS['FMAVFR <(EA)
Com any
BUILDING DIVISION FEES
IOed ropy b hereby fumished.
ertniRed copy la filed the city Inspersion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
URA I
COMPENSATION INSURANCE
(Thio nttlon need net WcompletedSis forces hundred dotlan
(S100)w
Icertify perfoperformanceat In the performance o(thework lorwhlch this permit is Issued,WATER
I shall not employ any person In any runner an as to become subject to the
Workers Comp.... ti n TawsmCallfnel.. Data
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should Wrome abject to the Worken'Compsuatwa provisions of the Labor
Code, you most forthwith comply with such provision or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebya(ilrm that them fat a construction lending agency for the perform
arm of the work for which this permit b bged (Sec. 3097, Civ. Q
Leader. Name -
Iced.e. Address
I cert By that l have read this application and state that the above information
bcorrect. I dgree to complywith all cilyand county ordinances and Yate laws
relating tobuilding costructton, and hereby authorize representatives of this
city to enterupon the above-mentioned property for inspection purposes.
We)
( agree to ave, Indemnify an d keep harmless the City of Cupertino
agaimtllabWtLn,jadgmenb,m sandexpeneswhichmaylnanywayacaue
against said Cl in uen of got ting ofthispermit
S l
CRFASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Reeei t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200F1'.
HEATER W/VENT/ELECT(
ENERGY FEE Y N—
PAID
Date Recel til
WATER SYSTEM/TREATING
NEW RESIDENTIAL PCMB. SQFT.
TOTAL:
B 'E '
SEISMIC FEE
Ax
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTy. • t :MECHANICAL PERMIT, FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
'
ALIFRORADDTOMECK
Date Receipt#
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL:
O
AIR HANDLING UNIT (OVER 10,01(s) C M)
CONSTRUCTION TAX
,
SlgnaNre o(AppBcant/Contrector to
HAZARDOUS MA ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
d Safety Cade, Section 75532(.)7
H❑yet No
Wnl the applies rat or❑ future building occupant use equipment or devlm
which emit hazardous all contamles a.a defined by the Bay Area Air
Qua lily Management District?
Yes have No
read the haze ous materlals requirements under Chapter 6.95 of
the Callfomia Health k Safety Code, Sectius25505,25533 and 25536. I
understand that if the building does not currently have a tenant, that It is my,
responsibility to nm fly the occupant of the requirements which at be met
prfortoivuance ofaCertfilcateot Occupancy.
EKHAUSTHOOD(W/DUCD
CONSTRUCTION TAX PAID:
HEATING UNIT CIO 100,00) BTU)
-
Date ROce1 iN
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
409:%
VENTILATION FAN( SINGLE RESID)
ISSUA �F 11 '1"E
Ate-�PFYLCrtfVsaj' -
�•t
t JJU
1 J
.
/x
City of 1,Ya
jlllp(�fiAj(f1
O v a
ISSUED BY: „
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OV10LOOD BTU)
ER
NEW RESIDENTIAL MECH. SQ.Ff.
Owror authorize
ne d agent Date
TOTAL:
OFFICE COPY