21130` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY N_OT-3D
fBuilding Project Identification B Y Q PERMIT NO.
BuRdiag Addre.s: f� l if 21130
-aL—p� 4 �� one: � � L
AL1-1 1_ c4zoa? CITY OF CUPERTINO-BUILDING DIVISION O r_
. c tra :.Na No: APPLICATION / PERMIT01 l
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONIAOLN
Archy/�ngf ee l ' LIc No:
of /�• QTY ELECTRIC PERMIT )EE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S pr DECLARATION LP
I hth SbdiRlrmtlat Dim.1 3.fthn Burp Won.o(Chapter9(mmmen APPLIANCFSRESIDENTUL OB DFSCRIP]lON
Ing with Sect1olnL7fq0r0s0s)of Divielon3 oflheguslnevandPro(cealonaCade,and my )
license la in fu effect. PANELS, L FD t4 r L
UP TO 200AWS
Limn Ch Lk.N J I_ IJ�./
Datc�� Cantraator
ARCHITECTS DECLARATION 701-I(DOAMPS
PQ!�COC ]understand myplayshallbeused aspubilcremNs. OVERIODDAMPS SQ.FT.FLOORARFA $/SQ7FT.
E U Licensed ProfenlOvl SIG_ ' 4h 9 o 1 /1
6 OWNER-BUILDER DECLARATION SP Ul 1 J�0
X, �a , owingfhererason.CSrtlame.em Business Con'ractoreLlcense ave loathe
following reason. 7031 S,Business and Profenions Code:An et r tp
pg— m.�*ywhichrequlre..permitlomvtmdalter,Impmve,d,.Ibh,orrepalrP'
anystm=mpriortolt.1.arame,alsomquim.theapplimntforsuch pertNttu EWER DEVICES / j
Ilk a signed statement that he k hmnsed pursuant to the pro"lora o! the Y
On{� Contmetorb License Law(Chapter 9(mmmencing with Section 7000)of Dial, st
VALUATION
tiEii sion3ofthelluslauseard Pma(emlov Code)orthathelsemmptlhemfromend _ ON
S° 777 the basis for the alleged exemption. Any violation of Section 70715 by any I L n 11co
1
<g Bant fora rmlbub sthca applicant 1 o(nmt more than OITILE7SSW17CHFSIgX'IVRES 3e —1
aPP pe � pP penalty
^ five 1,asunded owner ars of
ro NEW RESIDENTIAL ELECTR SQFf. STORIES TYPE CONSTRUCTION
7�n em I,as owner 1 the property,or my employees with wages a thele sole
rom(Sec.7KB,oda the weak endthe etroctureh not intended oioffendfor
q sok(Sec.70K tO a nOw Owner
f pmpcdy Code:The Contra even breve Law
S$ does.h.dossuchtoanownero throug hila .croplrlmprovntedth.tand OCC.CROIIP RFS.UNITS
who doneuchworkhimaeRorlhrwgh Maownemployeea,pcavided that such
Improvements am not intended orof(ered forsale.If,however,the building or TOTAL: f
Improvement dWld wllhmoneyearofcompletlon,the Owner-bu0derwill have
tt)rkurdca of proving that he did not Wild or improve for purpose oteak.). QTy, PLUMBING PERMIT FEE FTpOD7ANE APN
L,J L a.owner of the property,am exclusively co lauting with licensed pp IT UANCE
contractors to construct the project(Sec.7064,Bu.lness and Profv esuoCode: 1 i
The Contractor's License Law don na apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts fee such plojecl. -
with a
0 t et 1(-) ve
r(s)licensed pursuant to the ContractFEE SUMMARY
or'•License Law. BACK FLOW PROTECT.DEVICE
L-J I am exempt under Sec. B&p C for this man
FLES
Owner DRAINS FLOCg,ROOF,AREA,COND. SANITARY Y N'
. Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FD=RES PER TRAP SCHOOLTAX Y_ N
❑1 hereby.(firm that 1 have a.cearoome of consent m op(dnwrc,ora RECEIPT N
rertifla*eo(Workeri Compensatlonlvuranre ora certified mpythereof lSn.
3800,Lab CJ GAS IE EA.SYSTEM-1 OUTLETS PARK FY N
Paltry N
CoGAS EA. YIQd-0VER4(EA)
REC
m any
BUILDING DIVISION FEES
CertNed ropy is hereby te
Certified copy u(fled withh the city
IvpMlon division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE /^
(Ed.soutimored not becompleted lithe permit l.forone hundred dollars SEWER-BANITARY-STORM EA.ZOOFI'. Date Recei [N S,00
($1 I malty
WATER HEATER W/VENT/E.FCTR ENERGY FEE Y N
Imrtify that in the performance w
O(the weak for which this permit 1.toed, —
I shall not employ any person In any manner an v to became subject to the WATER SYSTEM/TREATING
Worked Compensation Lawso(GRforela.Date PAID
z Z Applicant
Z 0 NOTICE TO APPLICANT:If,after ran king this CarlfGte of Exemption,you NEW RESIDENTIAL PLMB, SQIF. Date Recei t#
should beccone subject to the Wmkers''Compewtlon provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provisions orthis permit shall be
domed. B N Pb
W
C CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
I hereby a(Rrmthat there ba construction tending agenry for the perform 1
Zance o(the work(.,which this permit is Wued(Sec.3097,CE,C,) TOTAL: [ (� ELECTRICFEE /
U O Evaders Name PLUMBING FEE Q
U. E- Lcader.Addresa Cry, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfy lhatl have read thhapplicationand atatethat theateve information /
IL Is correct.Igree to comply with all city and county ordinances and mate laws PERMIT ISSUANCE T2s 00 FEES PAID:
IL relating to Wilding construction,and hereby authorize representatives ofthls
F.. city to enter upon the above�menlionedp for inspection purposes. ALTERORADDTOMECH.
Z e�
Z (We)agree to e,IndcmN and armless the City of Cupertino Date Reeei t7f p l'-• ,
ag.barli.bNH dgmem., sand ran hlchmeylnanyw.ya a AIR H6NDLING UNIT(To 10,0D0 CFM) $DBTOTAL•
.gal al yin cars ort gra (this penNt ATR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
afOm.TPITAca"`/CdhTr&dor EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL SUR a
Will* applicant or future budding Omvpant store or handle hazardous HEATING UNIT(TO ICQOOD BTU) Date RCCeI IM
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Section 75537(a)L HEATING UNIT(OVER 1D0,000 RTU) TOTAL:
❑Yes �]Na
Will the zppllant orfuture building Occupant use equipment or devices VEN'ELATION I-AN(SINGLE RFMD) I DA7'Ej•38&
which emit harardoua ait contaminants as defined by the Bay Are.Air
. QualityManagcmeatDistrict? BOILER-COMPOHPOR100,010DIU) 1991
4Yes No APR 1 , 1
have madlheh a�ousnuteriabrequirementsunderChapter6.95of BOILER-COMP(OVEl00,ODOBTU
the California I Ir.l*h&Safety Code,Sections 75505,75533 and 75534, 1
understand that lithe Wilding does net corrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. Is' raf A.". '
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Omu pa acy. -
Owner or authorized agent Data
TOTAL: {/� ISSUEDBY: lwi u (
CI.Jy
OFFICE COPY