21016 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bull 'Project Identification PERMIT NO.
O� R¢' 75/ LLC. A fU/tA,d'T .✓O 3'a/ 21016
vera ams: one. Ip
44FS7,12,FW LZ CITY OF CUPERTINO-BUILDING DIVISION
e^^ ano:s"'me: t mem
Lic:Nccrj APPLICATION if PERMIT
/�ON //7r.CS Oi✓ fI ,.�J 77 5Vh BUILDING-ELECTRICALML BING-MECHAMCAL CATEGORY CONTROL
Archue t/Fagimer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 1:1 ❑ 1:1LICENSED CONTRAROR'B DECLARATION PERMIT ISSUANCE
I hereby cfic,.mthat lam Bcensedunder pessand so(Chaptar9(rommm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
i.gwftlice.h I.full 7(Xp)o(d vfect. ofthe8uslnesand Pr.(esslonsCode,and my
license Is in s (ortc a d effect. 3 PANELS
License CVs Cy�Lm.N.r,_3 7o a� )
Date Contractor_ OEC RATI ACJIO.J ,f/(A(f 1 Ll
ARCHITECTS DECLARATION OVER00AM15 \\
06 Z I understand my pions shad be used as pubdc rccsrds OVER 1000 AMPS SQ.FT.FLOG AREA 5/SQ.FT.
wO
`� Licensed Professional SIGNS ELECTRICAL
¢' OWNER-BUILDER DECLARATION
ut SPECIAL CIRCNT/MISC
t.., a Ihercby affirm tlutlam exempt(romthe Contntorb Licensee law(m the
F9 H^ following reason.(Section 70315,Bushes and Professions Code:Any city or TEMP METER OR IN
u'� county which requlrcsa permit tommtruct,alter,Improve,demolbh,orrepair
�e .5.E anystructure,prior to ltsissuance,alsorequinatheappilant for such permit to POWER DEVICFS
F6 file a signed statement that he b licensed pursuant to the provisions of the
Ow1. Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- NC POOL C
-- 30 aion3ofthe BusinsandProfesions Code)mthat he b exempt therefromand VALUATION
<F. the basis for the alleged exemption. Any violation of Seton 7015 by any O E SWI H D O D
applicant(or a permit..],jets the applicant to a dvil pe,lty of not more than
five hundred dollars(S50M. NEW D. AL EC SQ.FT. spolues TYPECONSDRIICTION
Z¢ ❑I,as owner of the property,or my employees with wages as their sole
compensation,wllldothe work andthe stmture b not intended of offered for
y ❑ sle(9ac.7064,Buslnessand Professions Code:TMCont.d.e,Lirerec Law
SB does not applyto an owner n(property,who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
G: whoduessuchworkhimselfortherugh hisownemptoyers,provided that wch
Improvements are not Intended arodered for sale.If,however,thebu:ding or AL:
Improvement issold within one yearofcomplatl.n,the owner-budder will have
thrkurden of proving that M did net Wlid or Improve for purpose of sale.), QTY, PLUMBI 1 FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cont"don;to construct the project(Sec.70K Business and Professions Code:
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT- IIIc
Wilds or Improves thereon, and who contracts for such pt
Rajes with a FEE SUMMARY
o t(admix)licensed pursuant to the Contractor's Lkemn Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under Sec. B &P C for this reason11 cc
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N�
• Owner Date RECEIPT
RFGPf-
KM
WORAN COMP ENSATION DECLARATION FIXTURES-PER TRAP SCI TAX Y_ N
❑I hereby affirm that I have a certificate of consent t.self-ironmRECEJPT X
certificate of Workers'Compensation insurance or a certified mpytheroof Sec. GAS EA.SYSTEM-11NC4 OUTLETS PARK FFP Y N_
3800,lab CJ �O/�Z.f`7
1'oliry M GAS G.SYSTEM-OVER 4 BUILDING D(EA) DING DI a
Com ny M VISION EGIiS
Certified ropy Is hereby tumbhed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified copy b filed with the city Inspection division.
CERTIFICATE OF EX`.. VEION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20oF7 Date Recef t#
(Thlssection need not W completed If the permit Is forone hundred dollars
($100)or les.) WATER HEATER W/VENT/F3.[CTR ENERGY FEE Y_ N_
I certifythat in the perfomunceof the work for which or
this permit Is bed,
I shall not employ any person in any manner no as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
-
0 Z Appllemt NEW RESIDEN IAL FLUB. SQ.FT. Date Recei t#
Z D NOTICE TO APPLICANT:If,after mak]ng this Cerfiicam of Exemption,you
Hshould become subject to the Warkers Compensation provisions of the Labor TOTAL:
N Coda you must forthwith comply with such provisions or this permit shall W BUILDING f/
W J deemed rcvoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE r�
CL C Ihercby affirm that there is,a construction lendingagenry n
(orthe per(orF ELECTRIC FEE
Z anceof the work for which this permit b issued&c.3097,Civ.C.) TOTAL:
V O Le.der.Name PLUMBING FEE
LL r Lander.Addreaa QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iani(ythatihavercadthbappBationandtatethattheabovelnfornution
1 is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and herebye.du imotpresentativea. ihib
F- Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu Parma Date Reecipt#
V against llab]litics,judgments,wnaand ex pens,which may In any way... AIR HANDLING UNIT(r010,000 CFM) SUBTOTAL:
against said City in mnsequ ence of the granting of this permit.
NA HANDLING UNIT(OVER 10,(X10 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocevpant store or handle harardoua HFATING UNIT(TO 100,000 BTU) Data Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Ilalth and Safety Code Seton 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
r7 Yea MNo VENII]ATIONFAN(SINGLERESID) ISSUANCE DATE
WRI the appllant or fuNre Wilding occupant use equipment or devices
which rout Management airrict? nano act defined bytW Bay Arca Air BOILER-COMP 100,IXp BTU) PAID Quality Management District? [-At&W
Yea No
have read the hav oua materlab rcquircmanb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) R
the California Health&Sa(ctyCode,Sections 25505,25533 and 25536. I SEP 1 d 1990
understand that if the building does not currently have a tenant,that it is my NEW RESI DENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be van
prior to sane of aCert ate Occupancy. City of Cupertino
Ofr or�I t or d Dat ISSUED BY:
1 TOTAL:
�vrr �rJ OFFICE COPY