22383 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY _
building Proert Identification PFRh9T NO.
Bui¢Jing AddrM: 22383
r. I rhom:
CITY OF CUPERTINO�BUILDING DIVISION r]—�^� I
em aao .Name: Lie.N. APPLICATION I PERMIT
BUILDINGELFl-IRICALML BWGMECHAMCALCATEGORY CONTROL.
ArchRea/Engineer. Llc No:
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ra� M17717—
Add. PERMTISSUANCE ❑ ❑ /� El
CONTRACTOR'S DECLARATION �1
Iherebydfbm tlutlama1m3ofuellusi wtand ofCh.pmr9(�and APPI.IANCESRE9DFMUL pB DESCRIPTION
inerse 1,in fau 7000)of Dhffect, fNe0uJvsand Pm(eWwuCode,and
Benue b la fuR fo d,0 V PANELS 11�J I
Lbense Ch � Lk..
Date Commtdo ( pre}L UP TO 200 AMS
ARCHITECTS DECLARATION 201- PS U M In
p�p�uu aO ZZ Iurdemmdmypbnssha0be�sednpubHe recede. - OVER 1000 AMPS SQ.FI'.FLOOR AREA $/SQ.FT.
fY u(j Llmrued Profeelovl SIGNSELECTRICAL ' Je 'n ces .
<<�Q OWNER-BUILDER DECLARATION SPECIALC1RC(11T/MI9C R � lAI 1`
ZF, IherebyafOrm that l am exempt from the Cantractor'a License law far the Per
1}
foBoaving rtason.(Schon 703]5,Business and Prolesbm Code:Any dry or ref m1
OR-Ci TEMP.METER OR POLE INS]'. 1
K muntywhld ,quknapem town d,et ,Impr ,dem h,ormpJr
q''� any.tr =.pr toibb ..,,sLwm-qubrstheappH=tfmmapemdtto I (']('�
FSO V Ble a signed statement that he b 11¢ POWER DEVICES naed pursuant in the provisions of the -I -{ j
Q6 R. Comraao/s Lkenee Law tChapter9(m.cing with Se:Lon 7000)of Did-SSV�,rhgNG FOOL ELECFUC VALUATION LI Jon3ofthe Susinessnd Prd mCode)orthathebexemptlhemfmmard
the Ivsb for the alleged exemption. Aey violation of Section 70315 by any
appbontforaperm bje theappllcanttoaavilpevhya..mthan �' �F�H �
Me hundred dollate(SM. NLW RESIDRDIAL EL ZIR
F1 T,ore owner of the property,or my employers with wages u theft sok SQ NSIRUCTION
compensation,w0l do the work,and the.imaure is wt bderded or OfterM for
sale(Sec 70K Ihulnns and Pmfeedons Code:The eorvn toe.License Law
does rot apply to an owner of property who builds or lmprovrs thereon,and C.GRO
G whodorseuchworkMmaelforthrnrghhis w employeea,pm dedthatmch
Improvements art not Intended or.ffued for vale.IL however,the building or TOTAL
Improvement b sold whhln ass yu rofcomplalon,the owner4kruBderwEl have
eden of moren
moving that he did t build or improve for Eau rpaae of sale.). QTY. PLUMBING PERMIT FEE
LI,ore net of the property,am esclu.ively mntr.ding with Rceneed FLOOD ZONE APN
mntnaors to mnsirud the pm)ea(See,70K Busause.d Prefmbm Code: PERMIT ISSUANCE
The Contractor.Lbeve Lw does mat apply to an ower d property who
holds,or Improv thereon, and who mmmacts for sueh pnp)tas with a ALIIILDRAEJ 4 VENT-WATER(EA)
ry➢4aeter(a)ho re ed pursuant to the CmtcadaL License Law. FEE SUMMARY
LJI.m exemp under Sec B k P C for thb reason SCK FLOW PROTFiT.DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y_ N_
Owns ECL RECFIPfg
WORKMAN COMPENSATION DECLARATION PIXIURFB PER TRAP SCHOOL TAX Y_ N_
hereby a(flrsn that I have a aMficate of cwuent b sell-mart,or REEIPT
mftffl to dWorkers'Cornperettionlwnna or a cerdff d copy thereuffSec. GAS EA.SYSTEM-1 WC40UII,EIS PARK FEE Y_ N_
mm,Lab C.I f
• g_s,(7rN�Policy0
.. 7 RECEIPT4
C[2nrtRdorp�y � � /1 GAS EA.S]STFMAVER4(EA) BUILDING DIV
ISION FEES -
GREASE/INWSIRL WASTE INTFRCEPTOR PLANCHECK FEE
lr]rGJ`-nified ropy bf0ed with the d[ylmptt[bn division.
.CERTIFICAn OF EXUAPION FROM WORKERS CREASETRAP PAID
COMPENSATION INSURANCE Mneed SEWER SANTEARv bTORM EA 200FE Date Recti t#
011aslon not becomplaed R the Fermat b foram hundred dollars
(5100)or teas.) WATER HEATER W/VENT/ELCCTR ENERGY FEE Y N
rtm
I artily that In the pedovnof the work forwhlch thb pend
,b issued,
I shall not employ any person In any manner n as to beanos subject to the WATER SYSITM/TItFATING
Wnrkers'Compensdbn Lawn./Callfomb. Date PAID
1'P SQFr, Date Remi t#
n hoot
Z p NOTICE TO AITLKANT:E,after maklry tits CertBlcam of Exemptbn,yw NEW RESIDINIIAL FILMS.
P N should become subjm to the Workers'Compevetbnpmdslom olthe L.bor TAL
Code,you must forthwith comply wXh such provbbv or this permit"I be
LU ] deemed revoked. BUILDING FEE
d .
CONSTRUKEION LENDING AGMCY EISMIC FE %
Ihembyaffl that there b a curstrualon lending agemy for the perform ELECTRIC FEE r
M = a rm&the.,kf.rwhkhthbpe,m hb ed C5,3M7,CN.C.I � TOTAL
V O Lender.N.me PLUMBING IT
LL F tenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icer Bythelhavertadthbappllatbnamr tet mthe.bovelnfom tiara
N braren].I.g.tommplywbhaBdtyaMd ntyordbun d• telaws PERMIT ISSUANCE FEES PAID: -<c4/
ry '^
} relatingm WlldmgmvtmrHon,aM hrnbyauthodurtpresentativenofthis a.[ I )
F Z dty to enter upon the above-mentlomd property fa irupeabn purposes. ALTFRORADDTDMECH.
- (We)agree to save,Indemnify an d keep humlee the city o/Cupertino
Date Rmci t#
agaWtlbbllltln,ydgrmrvs,mstaard expenen which may leanyw.yaenae AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
agal rsdd .e raeofthegrantingaftm.permX
y, AIRHANDLING(>MT(OVER to,000cF`) CONSTRUCTION TAX
Slgvture puont/Cno aDam EXHAUST HOOD(W/DUCE) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appacam orfutur¢be Uding omvpant store or handle havrdous HFATING UNIT(70 100,000 BM Date Recei t#
material as defined by the Cupertino MuNdpal Code,Chapter 9.11,and the
HeaBYaesMSilety,CodeW,i 75532W7 HEATING UNIT(OVER 100,000 BTI!) X„ TOTAL:
qui theappBmnt 6r.stare building oavpant use equipment or dev{m VENTILATION FAN WILE RESID) ISSUANCE DATE
whkh ends henrdaue air rentaMvn¢s as defired by the Bay Area Air
• Quality blanagemem Dwrial 110II,1SR-COMP QHPOR III,000 BM
Y.
/���t1,No
K.rend theh.nrdbue materib requireiems underChapter 6.95 o1 BOILE[t-COMP(OVf7t 100,000 RTU)
the Glltomb E[eaXh h Safety Code,Secibm 75505,2x533 and 25534. 1
undentardtlati(thebnenogdors notmmntFy hive atenant tlatitbmy NEW R75IDFMIAL MECH. SQ.F7
2rorlfb
malty to atuy¢the omv rddtherequiremenbwhkhrrustberruct
. Ocarpnry. Jaaen j�— ]56IlED BY:
TOTAL: -
OFFICE COPY