21405 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Pm'ed Identification PERMIT NO.
Building Address; 214,05
D L l! E
ners ams: /'� one: A
IFO&-P,r /Cbl JCKS z,-3 a� r' CITY OF CUPERTINO BUILDING DIVISION
Co actors Name: Lie.No: APPLICATION I PERMIT
M PWN,61Ne, Yo 293 BUfLDING-ELBCTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL s
Archited/Engincer. Lk.No:
T QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: S /g _gv J PERhgTISSUANCE ❑, 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l am licensed under provWons of Chapter 9(commore. APPUANCMRESIDENTAL JOB DESC MOVN���`'`�^p��
Ingweh inhill7000)of DlWect. flhe Buslnnsand Prolesslone Code,and my
license Sediol o de sion PANELS �¢,YJ/Ga'Giv
License Claes Contra r zsb `/P4'
Date' Lie.0 or
—UP TO 200 ANTS
ARCHITECTS DECLARATION 201-1 AMPS
po± 7b I understand my plana shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FrO .
E 5�j Llcenaed Profesebwl SIGNS ELECTRICAL
GGGG 6lG'tt OWNER-BUILDER DECLARATION
am SPECIAL CIRCNT/MLSC e
7 h'u1 Iherebyafon. thatIn7exemptfmmthed Profdoh Linde law(orthe LVA
po
following reawn.(SeRIon 7Q11 S,Buelnem and ProfessionsCode:Any dty or r"
OZ'"B IEh1P.METEROR POLE[NST. n \
any assigned totem lte that
he i,also sed pursuant
t the forevcom;of t e POWER DEVICES
01a a signed a versa La that he h r 9(con pursuant it the tion 7 ) of the II
Oq too3of the License law(Chapter9(commencing withxempt7000)of Divi. VALUATION
��OS elon3o(the Business and PMenloroCode)orthat hehexem)»therclromarW SWIMMING POOL ELECTRIC -
�' thebsoxfmthe.Ilegedexempilan. Anyvloletlonaf Sedlon7031.5by.ey
<2 appHuntforapert tsubjedatheappllcanttoadvllpemltygfnm=mthan OUTLETSSV✓ITCHESFI ES PATE
five hundred doll..($500).
ki ❑I,as owner of the roe NEW RESIDENTIAL ELECTR'- SQFr. STORIES TYPECONSDtUCT10N
property,or employees r their
compensation,Buswill iness and
work and thea Cod.:Th.
I,not ContrIntenactors
or offend for
q sale(Sec.apply
Buelnem and f property
Code:The C improves Lkeme Law
docsnotapply loan owner ofpropertywhobuildsor Improvesdedrcoryand OCC.CROUP - BES UNITS
who doessuch entsam khimself ed orough Msowals.If oweerthedlhataueh
Improvements sods Intended earofe foreak.If,h er-p ilderwdingoe TOTAL:
Improvement bwld withinonayearofcompldlon.theowner-buBderwBlhave
tlg;,)rurden of proving that he dict not build or Improve for purpose ofule.), QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contracto.to cmulauct the projM(See 7004,Business and Profevlmu Code: �'L, 4a1
The Cont.cmr's License Law does not apply to an owner of property who ALTER A VENT-WATER(EA)
builds or Improves therron, and who contracts (or such p(ujsds with a FEE SUMMARY
cq)gpadd
or(s)Bmnsed pu.usnt to the Contract'Lkxnsa Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under,Sec. B k P C for this reason
OwnerDRAINS FLOOR ROOF,AREA,CDND. SANH'ARY Y N_
RECEIPT M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
An, hereby affirm that 1 have a ceMl(ILate of consent to opytherem or RECEIPT a
rtl Late of Works.'Compevatlonlruunnceoeacertlfkd copy Mereaf Sec. CAS FA.SYSTEM-1 WC.4 ounmS PARK FEE Y N
poI1ryolis Lab C.)R RECEGAS FA.SYSTRM-OVER4(FA) DING Tp
Cam any BUILDING DIVISION FEES
Certified copy h hereby tume city
IX Cert#led copy h filed with the city Ire)xxtlon division. CREASEANDUSTRL WASTE INTERCEPTOR PLAINCI[ECK FEE
CERTIFICATEOF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XpF1• Date Recel t#
R.old bra need not be completed If the permit hloraiie hundred dollars
(51 I )camlcv.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertifylhal Nthe performanceo(the work forwNch this permit is hosed, —
I shall not employ an/person In any nunner u u to become subject to the WATER SYSTEM/TREATING
Workdx'CompenuHon Lam of California.Date PAID
* Z ApplicaNOTICE
NEW RESIDENIIALPLMB. SQFT. Dale Remi t#
Z Q NOTICETOAPPLICt to the
after making
mper ationkatmfons of the Labor
H C-dlshoulbecome subject iothe Worksith.mheruatlanprothloraafthe Labor TOTAL:
LUN Cade,dmucelforthwilhcomply withsuch provhioru orthh pe.nit shallb.
`� deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyafOrenthal there faacerulruction lending agency for the perform- ELECTRIC FEE
7 Z once of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U Q Lender'.Name Oct PLUMBING FEE
LL I— LmdelsAddreu QTY. MECHANICAL PERMIT IEE MECHANICAL PLUMBING
FE FL•E
O W Icertifythatl have madthhapplicationand statelhetheabovamfomutian
1.
cc agree to complywith all city and county ordinance and state lawn PERMIT ISSUANCE FEES PAID:
} 1 relating to building construction,and herebyauthmLee reprcsenmtiv..f this -
y city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to asve,Indemnify and keep harodees the City of Cupertino Date Recei t#
V against liabilities,pdgments,mks and expenses which may In anywayamue AIRHANDLINC UNIT CFO 10,000 CFM) SUBTOTAL:
agalwtsald Cityinc s ce ofthe grantinsaLWa rmlt. '
-�:� �e , 9-1,?^oI AIR HANDLING UNIT OVER10,ODOCFMI CONSTRUCTION TAX
Signature of Ap Lant/Contractor C�—� K Date ! L EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAlARDOUS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU)
vmer1a1 as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Reuel t#
Health and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ YesNo
Willtheappllcant o fisrum building oompant use equipment or devices VENIILATION PAN(SINGLE REND) ISSUA ,�T'E
which doll hazardous air contaminants as defined by the Bay Area Air AS
Quality Management District? BOILER-COMP DEBTOR ID0,000 BT10 t
4 Yes {�No I Ines QT
have rcadlhehuammsmaterlalsmqulmmnntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) }� r NI
the Callfornh Health h Safely Code,Sections 25-1415,25533 and 25534.I
u ndersta nd that if the building does not currently have a tenant that It h my NEWRESTDEMIALMECH. SQFr
responsibility to notify the occupant of the requirements which moat be met
prImWess.sac of Ce iawdOoccu au t . pal5•r5
Ownermaulhorl gent Dale
TOTAL:
OFFICE COPY