21617APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
373 ✓y<cto lKcv
PERMIT NO.
21617
!j� jt7L! ane.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION if PERMIT
BUILDINGE1ECTMCA1.PLUMBING-MFCIdAMCAL
a
�ZrZ� IO
Lic.
sN —tS
CATEGORY
CONTROLN
Architect/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addmss� L/ga�,Q
PERMBTISSUANCE
❑ ❑ j �y(
L j 5j
LICENSED CONTRACTOR'S DECLARATION
T hereby affirenthat l am licensed under provisions of Chapter9(mmmene,
ingwlth SeMon7000)af Dlvlaion3oflhe Butlnesand ProfealonsCode,mdmy
limnselslnfu fa ddfcR. Q —
Llmnse Llc. p
Dale Contactor
ARCHITECT• DECLARATION
I undeaknd my piss .hal be used apubkc rcmrda
Licensed Professional
OWNER -BUILDER DECLARATION
I ereby affRmthat l am exempt(romthe Contractor'. License Law for the
follo greason.l5ecHon 7MLS, Business and Professions Code: Any cityor
county Ichrequiresapermlttommtmtl,alleglmprove,demalkh,orrepalr
anyrtm priortoltskwsnca,akorequlreaheappllcant for permit
ilia a sign. atement that he k licensed pursuant to the proWioru of the
Contractor's L erne Lew (Chapter 9 (mmmenaing with Section 7000) of Divi.
elon3ofthe Bua and Pro(eabtuCode)orthat he ezemp[there(romand
the basis for the ed exemption. My violation of Stolon 78115 by any
app0ont fora perms objects the applicant to civil pealty dna more than
five hundred dollars
as owner of the p ety, or my employee with wage. as their mk
compematlon,w0ldothew and thestmoom b not intended or offered for
sale (Sec 7066, B I.I. and essioru Code: The Contratlor's I.IceNG law
does not apply to an owner. d P rty who builds or Improves thereory and
whodoev suchworkhimulf orth Nsoweemployees,providecithatsach
Impmvemcntsare notimendedmeffe for sale. IL howevegthebuilding or
Improvementksoldwlthlomeyearof letlon,theowner-bullderwilllave
t rden of proving that he did out bull Improve for purpose ofak.).
as owner of the property, am exdua IF contracting with licensed
contacroato mns(roctthe project (See 7046,B ea and Profmbes Cad e:
The Contactors Llmn.e I�w dont net apply to a caner d property who
bulkl. ar Improve tharcon, and who comm f ch ptojem with a
�qN(+dor(s) licensed pursuant to the Contractor'. Lien Law.
1_I I am exempt under Sec. B k P C for this. reason
AITLIANCESRESIDENTIAL
JOB ESCRIBI7ON
�•]�� /
'`
PANEIS
00AMIP5
OVEROVER 1000 AMP$
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNS E TRICAL
SIPECfAL T/
pPS,IP. O IDOL I KY
PpW);g
It
SW1ML11 EL C
OUTLETS
VALUATION
'
W AL M•�� �'�'
STORIES TYPE CONSTRIKT[ON
DIAL:
QTY. PLUMBI O MI FEE
PQtMR ISSUANCE M
I d
OCC. GROUP RES. UNITS
FIADD7ANE APN
,��-DRAIN 4 VENT • WA ears)
BACK FLOW PROTECT.
FEE SUMMARY
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N_
RECEIPT N
Owner Dale
WORKMAN COMPENSATION DECLARATION
�s�T.
I� hereby affirm That I have a certificate of consent d opythereo or
certifiateofWorkees Compewtlonlauran ora certifkd copy thereof (Sec.
3800, LabCy I 9 4) �N i! � �'j 9
Po11cyN r'1 7
SCOOOL TAX Y_ N
REC=N
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE Y _ N
RECE(FTM
_ a�V--,Y_,�.
Camoany �%eiiuF r�V!/
GAS F.A. SYSTEM-OVER4(EA)
BUILDING DIVISION FE ES
I I Certified copy is hereby
iLa��IlCertitied copy i. filed with the city Wpectlon division.
with the
CERTIFICATE OF F3(EMPIION FROM WORKERS'
COMPENSATION INSURANCE
C17J eed na be completed if the pemdt is for one hundred dollen
(5100)or lead
Imrtifythalintheperformanceo k(orwhlch this permit is issued,
1 hall fiat employ any person In any manner Io become subject to the
Workees Compensation lawsof Glifomk. Date
Applicant
NOTICEco esPLICAM:U, after makingthis at ionCertificate
prois Exemption, You
should become forth tothe Workers' Compemalons rovhlomofthe Labor
Code, you must forthwith comply with such provisions orthk permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirrnthat there i a construction lending agency forthe perform-
an l� work for which this permit is Issed(Sec. 3097, CIv. C.)
Lender'. fxaYlt�
lender's Address
I ceetllythatl have read t Bcationand nate that theabove information
is mrtaat. I agree to comply with a and county ordinances and nate law.
relating to building corstructlon, and suthodu representative of this
city to enter upon the above-mentioned prop mWpectlonpurposes.
(We) agree to ave, indemnify an d keep Its the City of Cupertino
against liabilities, pdgments, mrt. and expenses which inanywayacerue
against said City In em.equ ence, of the granting d this It.
GREASE/INDUSML WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel to
GREASE TRAP -
SEWER -SANITARY -STORM EA. WORT.
WATER HRATERW/VENT/ELECTR
ENERGY FEE Y' N
—_
PAID
Date Retei tilf
WATER SYS17M/TREATING
NEWRESIDENTIALPf.MR SOFT.
TOTAL:
BUILDING
FEE
Torn1; a.x��
.W
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT PGE
MECHANICAL FEE
'24100
PERMITISSUANCE
FEE —PAID:
t ALTERORADDTOMECH.
be Recei tis
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING uNrr (ovFR 10,030 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor 'Date
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or future building occupantstomor handle hauedous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
lkalth and Safety Cadr tllon 25532(a)?
❑ Yea ,L��eNo
Will theapplicant or future building occupant use equipment ordevices
which emit haurdous air mntaminxnte as defined by the Bay Area Air
Quality Management Dl. ci'!
QYes No
. yes ad the hazy ous materials requirements under Chapter 6.95 of
the Ca lifogagrNealth building Code, Sect ioa25505,-atonand , that
undo II I(Ihe building don film re ave. hick that b is my
ons iii ady the occvpan of the content. which rrwsl be reef
j
riorI es of A in p n .
FXHAUSTHOOD(W/DL'C)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,ODO BTU)
Date ReCeI tN
HEATING UMT(OVFR IIp,lX10 BTU)
TOTAL:
VENTILATION FAN (SINGLE RISID)
iwm�yDATE
1'
OC.tT (Wl
C07/
a '
a
ISSUED
BOILER -COMP OMP OR 100,IXU BTI])
BO LER-COMP (OVER 100,000 BTU)
NEW RISIDf:NT1AL MECH. SQ.FT
.�>^coshr authodud agent Date
TOTAL:
`
OFFICE COPY