19551 APPLICANT TO FILL IN INFORMATION WITHIN RED LI ES — USE BALL POINT PEN ONLY
Building Project Identification P1111MITNO.
Build tog�i L vl C. C 19551
ZPFers ossa: ^ n B O none: A
oXA21t W- �( l 1 CITY 'CUPERTINO-BUILDING DIVISION I ' O
ra
C '°game: r LIc.N APPLICATION / PERMIT
pr hltm En er. BUILDING-ELGCTRICALI'LUMBING-ME(CF3AMCAL CATFOORV CONTROL `83
� Lk.No: .7
QTY ELECTRIC PERMIT ) FEE BUILDING PERMIT INFO
7 Address: �l d. PERMITISSUANCE
LICENSE CO. TRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Cha pter 9(commum& APPLIANCES-RESIDENTIAL JOB DFSCRII7ION
inlic&with In fan to.a(DlWdon3 ohne Butlnessand ProfessloneCode,and my
Lt.. Is ie tali force and df. PANELS
License Ctss Lic.p
Date Contractor I
ARCHITECT'S DECLARATION . 701-1000 AMPS
GG zp (understand myplaru dull be used upubBc records OV1iR 1000 AMI5 SQ.17.FLOOR AREA sm.ET.
Licenced Professional SIGNS ELECTRICAL
<<alL7" OWNER-BUILDER DECLARATION SPECIAL CIRC SC
7z;'rr
foll
z Iherebyafll.that I am exempt front the Conaractor's License Law for the [--O/ O
qqqqqq owing means.(Section 7031 S,Business and Professions Code:Any city or �J
F H county which requites a permit to muted,alter,improve,demolish,or repair TEMp.ME1TR DRI'OLE INSf.
q� anystructure prior In it Wua nce,alw requires the applicant for such permit to
!S Ole a signed statement that he t licensed pursuant to the provisions of the POWER DEVICES
^r�Ow Contractors License Law 9(mmmentlngwithSect1on7000)ofDlvl-
G1,3 G hes SWIMMING POOL ELECTRIC
Won 3ofthe Business and Profemloru Code)orthat hetexempt themlromend VALUATION ..
the basis for the alleged'exemption. Any violation of Section 7°315 by any
a❑j
applicant for a permit subjects the applicant to a civil penalty of not mare than OUTLETSSWI7CHESEX'NRES
(Eve bun.owner
hepr. NEW RESIDENTIAL ELFOTR SQd7,
z ❑I,as owner o(tbe property,or my employees with wages as their osis STORIES TYPE CONSTRUCTION
Fa compensation,will do the work and the structure in am Intended or offered for !>3
❑
sale(Sec.704k Business and Pre(emimus Cade:The Contractors Limine law
$ does not a pply to an owner of property who builds or improves t hereon,and OCC.GRON' RES.UNITS
whodue...chworkhi.tf.rthroughbisownempl yee,providedthatooh
Improvement are not WendM or9(fered break.lChowever,thebuildingor TOTAL: t�J�
Improvement esold withinoneyearofcompletion,the owner-bullderwlll have
tl(Lkurden of provingthat he did net build orlmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEEn7,00DZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the prefect(Sec.7044,Business and Professions Code; Zre'D
the Cont or License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds mp thereon, who contracts for such proiem with a
< oHe)1 need r nt.to a Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am erupt un er B&P for reawnOUTSIDF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIVE
KMAN COMP ATION DECURA ON FDCnJRES-PER TRAP SCHOOL FAX Y N
❑1 herebateof artless that I have o rtlBcat of consent m op theme,ora RECEIPT a
c800,[Aeo(Worken'Comperwllon Insurance ora certlflad ropy themo(�ec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N—
Polic Lab C.)
Policy a RECEIPT p
Com an CAS IiA.SYSTEM-OVER 4(EA)
Y BUILDING DI VISION FE ES
CertlRed copy t hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI[ECK FEE
E]Ccrtl(led ropy t filed with
the the city IvpeRion division. 60
CERTIFICATE OF MM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 70OF1' - ! Date Remi 1#
(fhb seRton need not be completed If the permit t for one hundrctl dollars
(f100)orless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Isnotrtify emplhat oy
the person mor
ism mannworker
so as to became
eetaob noted, —
I shall scat employ any person In any manner n ss m become eubfect to the WATER SYSTEM/TREATING /�4—�
WoCompensation Laws o(Gt
lifom .Date PAID
Z Applicant Z O NOTICETOAPPLICANT:to the
after rr 'Comht ationlcate of Exemption,you NEW RESIDENTIAL PLMB. SQ.PI'. Dale Remi t#
should become subkcl tothe Workare'Compematlon provisions ofthe Labor 3 TOTAL:
~ fA Code,you must forthwith comply with such provtlons ortht 8r B permit shall be 5 2 p
LU > deemed revoked. FEE
' .
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE r s
Thereby III tlutthcre Is tructlon lending agency for the perfarm TOTAL: 9'� S
Z once ufthewor w r ed(&c 3097,Cw;.) 3 ELECTRIC FEE 53
U0 lenders Name PLUMBING FEE f
LL F lender's Address Qtt. MECHANICAL PERMIT FEE MECHANICAL FEE ,s'3
O W Imnilythatlluve 1 applTca lonandatatethat eabovelnformallon
1 fro to comply with a B city and county ordinances and pate lawn POWITISSUANCE 17'&71 FEES PAID:
} N rel ngt.bull Ingcomuuctlon,and herebyauthmoc.representativeeuftht
Z yto enter .the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Dale Recei t#
—
(Weis e to save,Indemnify an d keep harmless the City of Cupertino P
ag.m.til Titles,ju asnde.p.mo.whichmayl.a.y.syaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
sgairet IdC In a ofth. arttrgrdfthi.ps It.
AIR HANDLING UNIT(OVER 10,o0OCFM) CONSTRUCTION TAX «x714
S atumo Applicant/Contras r DAA EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7 RDOU MATERIALS DISCLOSU E
Will the applicant or Futuro building occupant store orhandle haea dous HEATINGUMT(TO100,0DORTEt) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the �I
Hrahhand Safety Code Sectlon 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ( lb
I—I Yes M No
til the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) Isrjl®Rf[fvs[iA'1•E
which emit hazardous air mntaninant
nta as deed by the Bay Area Air �d�L�
Quality Management Dbtrl07 BOILER-COMP C3 W'OR 100,000 HT-W
Yes ❑❑
�t e read the h=z mso
vmaterials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,00)BTU) APR 1 X 79YU
the California Health&Safety Code,SMlmu 755°5,75533 and 75534.1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met Gty 0f ly)��►l3.a�
pdor to lssuanmofa GrliBcaw.fOccupanry. 7
Ownerorauth.Axndagent Date
TOTAL: 9'
-:�? ISSUED BT*IW�UJ��41�-mar+
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LI ES — USE BALL POINT PEN ONLY
Building Project Identification P1111MITNO.
Build tog�i L vl C. C 19551
ZPFers ossa: ^ n B O none: A
oXA21t W- �( l 1 CITY 'CUPERTINO-BUILDING DIVISION I ' O
ra
C '°game: r LIc.N APPLICATION / PERMIT
pr hltm En er. BUILDING-ELGCTRICALI'LUMBING-ME(CF3AMCAL CATFOORV CONTROL `83
� Lk.No: .7
QTY ELECTRIC PERMIT ) FEE BUILDING PERMIT INFO
7 Address: �l d. PERMITISSUANCE
LICENSE CO. TRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Cha pter 9(commum& APPLIANCES-RESIDENTIAL JOB DFSCRII7ION
inlic&with In fan to.a(DlWdon3 ohne Butlnessand ProfessloneCode,and my
Lt.. Is ie tali force and df. PANELS
License Ctss Lic.p
Date Contractor I
ARCHITECT'S DECLARATION . 701-1000 AMPS
GG zp (understand myplaru dull be used upubBc records OV1iR 1000 AMI5 SQ.17.FLOOR AREA sm.ET.
Licenced Professional SIGNS ELECTRICAL
<<alL7" OWNER-BUILDER DECLARATION SPECIAL CIRC SC
7z;'rr
foll
z Iherebyafll.that I am exempt front the Conaractor's License Law for the [--O/ O
qqqqqq owing means.(Section 7031 S,Business and Professions Code:Any city or �J
F H county which requites a permit to muted,alter,improve,demolish,or repair TEMp.ME1TR DRI'OLE INSf.
q� anystructure prior In it Wua nce,alw requires the applicant for such permit to
!S Ole a signed statement that he t licensed pursuant to the provisions of the POWER DEVICES
^r�Ow Contractors License Law 9(mmmentlngwithSect1on7000)ofDlvl-
G1,3 G hes SWIMMING POOL ELECTRIC
Won 3ofthe Business and Profemloru Code)orthat hetexempt themlromend VALUATION ..
the basis for the alleged'exemption. Any violation of Section 7°315 by any
a❑j
applicant for a permit subjects the applicant to a civil penalty of not mare than OUTLETSSWI7CHESEX'NRES
(Eve bun.owner
hepr. NEW RESIDENTIAL ELFOTR SQd7,
z ❑I,as owner o(tbe property,or my employees with wages as their osis STORIES TYPE CONSTRUCTION
Fa compensation,will do the work and the structure in am Intended or offered for !>3
❑
sale(Sec.704k Business and Pre(emimus Cade:The Contractors Limine law
$ does not a pply to an owner of property who builds or improves t hereon,and OCC.GRON' RES.UNITS
whodue...chworkhi.tf.rthroughbisownempl yee,providedthatooh
Improvement are not WendM or9(fered break.lChowever,thebuildingor TOTAL: t�J�
Improvement esold withinoneyearofcompletion,the owner-bullderwlll have
tl(Lkurden of provingthat he did net build orlmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEEn7,00DZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the prefect(Sec.7044,Business and Professions Code; Zre'D
the Cont or License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds mp thereon, who contracts for such proiem with a
< oHe)1 need r nt.to a Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am erupt un er B&P for reawnOUTSIDF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIVE
KMAN COMP ATION DECURA ON FDCnJRES-PER TRAP SCHOOL FAX Y N
❑1 herebateof artless that I have o rtlBcat of consent m op theme,ora RECEIPT a
c800,[Aeo(Worken'Comperwllon Insurance ora certlflad ropy themo(�ec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N—
Polic Lab C.)
Policy a RECEIPT p
Com an CAS IiA.SYSTEM-OVER 4(EA)
Y BUILDING DI VISION FE ES
CertlRed copy t hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI[ECK FEE
E]Ccrtl(led ropy t filed with
the the city IvpeRion division. 60
CERTIFICATE OF MM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 70OF1' - ! Date Remi 1#
(fhb seRton need not be completed If the permit t for one hundrctl dollars
(f100)orless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Isnotrtify emplhat oy
the person mor
ism mannworker
so as to became
eetaob noted, —
I shall scat employ any person In any manner n ss m become eubfect to the WATER SYSTEM/TREATING /�4—�
WoCompensation Laws o(Gt
lifom .Date PAID
Z Applicant Z O NOTICETOAPPLICANT:to the
after rr 'Comht ationlcate of Exemption,you NEW RESIDENTIAL PLMB. SQ.PI'. Dale Remi t#
should become subkcl tothe Workare'Compematlon provisions ofthe Labor 3 TOTAL:
~ fA Code,you must forthwith comply with such provtlons ortht 8r B permit shall be 5 2 p
LU > deemed revoked. FEE
' .
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE r s
Thereby III tlutthcre Is tructlon lending agency for the perfarm TOTAL: 9'� S
Z once ufthewor w r ed(&c 3097,Cw;.) 3 ELECTRIC FEE 53
U0 lenders Name PLUMBING FEE f
LL F lender's Address Qtt. MECHANICAL PERMIT FEE MECHANICAL FEE ,s'3
O W Imnilythatlluve 1 applTca lonandatatethat eabovelnformallon
1 fro to comply with a B city and county ordinances and pate lawn POWITISSUANCE 17'&71 FEES PAID:
} N rel ngt.bull Ingcomuuctlon,and herebyauthmoc.representativeeuftht
Z yto enter .the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Dale Recei t#
—
(Weis e to save,Indemnify an d keep harmless the City of Cupertino P
ag.m.til Titles,ju asnde.p.mo.whichmayl.a.y.syaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
sgairet IdC In a ofth. arttrgrdfthi.ps It.
AIR HANDLING UNIT(OVER 10,o0OCFM) CONSTRUCTION TAX «x714
S atumo Applicant/Contras r DAA EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7 RDOU MATERIALS DISCLOSU E
Will the applicant or Futuro building occupant store orhandle haea dous HEATINGUMT(TO100,0DORTEt) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the �I
Hrahhand Safety Code Sectlon 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ( lb
I—I Yes M No
til the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) Isrjl®Rf[fvs[iA'1•E
which emit hazardous air mntaninant
nta as deed by the Bay Area Air �d�L�
Quality Management Dbtrl07 BOILER-COMP C3 W'OR 100,000 HT-W
Yes ❑❑
�t e read the h=z mso
vmaterials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,00)BTU) APR 1 X 79YU
the California Health&Safety Code,SMlmu 755°5,75533 and 75534.1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met Gty 0f ly)��►l3.a�
pdor to lssuanmofa GrliBcaw.fOccupanry. 7
Ownerorauth.Axndagent Date
TOTAL: 9'
-:�? ISSUED BT*IW�UJ��41�-mar+
OFFICE COPY