21126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 4 D Z,6,
Ifultding project Identlfleatlon X7 :1- PERMIT NO.
Building Address:
g-� 2112
ne a Name: one:
M q2k"pAj L (-VF P CITY OF CUPERTINO-BUILDING DIVISION
6_0 Co act r'e Na . k. y APPLICATION / PERMIT
I BUILDING-ELECTRICAUPLUMBINC-MECHAMCAL CATEGORY CONTROLN
An hiil/Fngineer.- G E� Lk.No:
�nJJ - J Q7Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERhITISSUANCE
LICENSED CONTRAROR'SDECLARATION
IhingwithS on7Othat lalvigm3 dunderheBu provisions ofCha r9(rommmc- APPLIANCFSRESIDENML
Ill...h Is 1.fi. eic0eandeffect, fthe Buainessand Pro nano sCod.,andcry JOB DESCRIPTION
LIC,Date Cn!' ` and
PONTIS W I , 1
ARCHITECT'S DECLARATION 201-10DOAMPS J v
C4 Z I understand my plareshag be used as public records OVER I ODO AMTS SQ.FF.FLOOR AREA $/SQ.FF.
O
Licensed Professional SIGNS ELECTRICAL a Y
6 OWNER-BUILDER DECLARATION ..` - J A�
7' a hercbya(fi mthatlam exempt Commences(romthCommencesLicenseSPEGIALCIiCUIT/M1SC
ore Llcenlaw(or the J L O
6 2following reason.(SMion 7031.5,Business and Professions Code:Any dtyor
I"'c9 muntywhlchrNulrusapermlttommtmc"ter,impmve,de=lBh,orrepair TEMP. OR P%F.IF{ �rr�
anystmdum priorto Ra Wuame,alsomqulresthe appBeant forsuchpermit to `�*rJ—
ruG (� file a signed statement that he Is licensed pursuant to the provlalore of the
3 w Contractor's License Law(Chapter 9(Commuencing with Bodies 7000)of Dlvl-
�OS Non3oflhe Busineeeand ProfsnimuCode)arthat hebexempHherefromand &PA VALUATION
{�6 the basis for the alleged exemption. Any violation of Section 70315 by my O L IFS 1 �s
{r�rrO� applicant fora permit subjects the applicant to a civil penalty of not more l ban L e
fivehundrcddolhr employees, NEW SQ.FT. SCO
F-11,..owner o(the property,or my employwith wages as their sole WFS TYPECONSTRUC'DON
c peneatlan,wlllda the work and thestmcture bnoHntended or offend(or N"'f/
qvie 6ec.706y Busb�esa andlamfesslom Code:The Contradota Licereelaw 7 fc
does not apply to an owner of property who builds or improve,thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhimsel(orthrough hieownemployees,provided that such
improvements are not Intended oroffered forsale.If,however,the bulldingor TOTAL: 1
improvement 6sold wlthln owyearof compldlon,the owner-budderwlll have
t"rden of pmving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE p)-pO zOKEE ApNr
U L as owner of the property,am exclusively Contracting with licensed PERMITISSUANCE
contractors to Coretrud the project(Ser.7044,Businessand Professions Code: I-2.t
The Contractor's License law does nut apply to an owner of property who ALTER-DRAIN VENT•WATER(EA)
builds or Improves thereon,and who Contracts for such ptojects with a
mi�t ador(s)Bcensd pursuant to the Gontndoe'sUcenss Lew. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under See. B&P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
. Owner Dale RECEIPT N
WORK MAN COMPENSATION DECLARATION pIX•NRFS PER.TRAP SCHOOL TAX Y N
❑1 hereby d(trm that I have o Imum to of convent m spythwn,ora RECEIPT N
certificate of Workers'Compereatlanlreunnceora certl(Ied Copythereof(Rec.
3800,Lab C.) GAS EA.SYSTEM-1INCA OUTLETS PARK FEE Y N
P.cc Y CAS FA.SYSTEM.OVER4(EA) RECEIPTp
Com any BUILDING DIVISION FEES
Certified Copy is hereby turnGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Certified Copy V(fled with the e city
ity Inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARY-STORM EA. Date Recei t# ,W
(Fhlseedbn need not becompleted If the perms V(Drone hundred dollen kr
($100)or lea.) WATER HEATQt W/VENT/ELFLTR ENERCYFEE Y N
I certify that In the performance of the work forwhich this permit Is blued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'CompensatlonUmof California.Date PAID
z Z ApplicNOTICE
rat NEW RESIDENTIAL PLMB.-_SQ.FT. Date Recei t#
Z NOTICEco APPLICANT: aherrs'Co persationhis profscAe.f Ens ofthe ,you
Code,shoulyou
subjecttothe plywit'CamprovisinprovWorermit shall
�.(/ TOTAL:
W N
Code, rtked.forthwith Comply with such provisions Duthie permllshall be J h
j deemed revoked. 1L s
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a Construction lendingagenry for the perform- ELECTRIC FEE
Z ane of the work for which this permt is Issued(Sec.3097,Civ.C.) TOTAL: I 1
(� O Icnderlr Name PLUMBING FEE '7159
ILS Icndcrb Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 4-p
OW I cedlfythat l have read thisapplimtionand statethatthe above Information /�a
(1 ismrrect.I agree to comply with all eltyand County ordinances and gate laws PERMIT ISSUANCE �Zs,zl FEES PAID:
>. 0. to building Construction,and hereby authorize representatives of this
I- U) city to enter upon the above-mentioned property for inspection pis rposes. ALTERORADD'PDMECH. p �Q
(We)agree to vv demnity a keep harmless the City of Cupertino Date ReCCI t#
V against lhbllties ' mens, dexpe hkh yinanywa accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL•
agairet nConeryue the oft pe, - AIR HANDLING UNIT(OVER IB,ODBCPM) CONSTRUCTION TAX
g ore of p oniradrn Da IXHAUSTHOOD(W/DICT, CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO RE
Will the applicant or future building occupant store or handiehazardoua HEATING UNIT(TO 100,000 BTW Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the -
Health and Safety Code Secllun25532(a)? HEATING UNIT(OVER 100,D00 BTU) TOTAL:
❑ Yes No
Will lheapplicenl er utumbuildingoccupantu,eequlpmentordevices VENTILATION PAN(SINGLE RESID) 1$gUAI.] DATE'JT'Z�j
which Cmu havrdous air mnumnica is as defined by the Bay Area At,
.W
Quality Management District? BORER-COMP(3HPOR 100,ODD BTL7) _
4Yea ❑❑No 11991
haBe read Healthe h
ardfet manic,Sections 2menb under Chapter 4.I of BORER-COMP(OVII2100,00)0N) PR
the
ersta dt Health ASafety Code, otc Sections t and nan,that
understand that?(the building don not CorrenOy havealenanq thJt ltbCry NEW RESIDENTIAL MECH. $Q.FT.
responsibility to notify the occupant of the requirerrenb which must be met city A#ti'
..ya -
Prior to issuance of a Certificate of Occupancy. I Y
Owner or authorized agent DateT�aa�raa
TOTAL: a ISSUED BY: V'••'r/
OFFICE COPY