20440 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONVi
Building project Identification /( a{/) ) PkRMITNO.
Building Address: u~JL 1 �� � 2 0 7 7 5
weer• ares one: A A A
CITY OF CUPERTINO-BUILDI GDIVISION
• co .r �: Lic.No: APPLICATION /PERMIT [(/
inc, BUILDING-ELDCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL a
Arcs 'neer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
LICENSED CONTRACTOR'S DECLARATION
PERMITIS5UANCE ❑ ❑ 1:1Ihe7that Ia under proofC9c APPLIANCES JOB DESCRIPTION
IngwithSectionOOO)ofDivisio3oftheBusinessland ProlssionsCvde,and
my
license is In f ddlm. C PANELS
License Cla Lk.N M �p
nate y lam ^ cono-aRnr - � IL
LIe✓` CHITECPS DEC ON rV I 201-1000AMPS
niz I understand my plans shall be used as W public records. OVER IOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
HE Licensed Professional SIGNS ELECTRICAL
6<w OWNER-BUILDER DECLARATION
SPFGIALCIRCUIT/M
owing .. lhatiam0I.S.Business fromthe Contractors Llanx Law fort he
f ntygreason.imlon7 ttomtmdandrimp ons Code:Any cityorp l:, TEMP.MEIFROR EINSf.
countywhkh requlresa Permite,alsorquirestheapmvgdemolsh,orrepalr
ray atrvrnrrepdortoitshwan=,aso sed pursuant
to the (.visionor such of Lm POWER DEVI
cG Q V file a signed statement that W s licensed pursuant to the provisions of the
Contractor's LicerseLaw(Chipter9(=mmencingwith SrcBon7000)of Divi- SWAIMING LELECTRICVALUATION
mOs sion3ofthe Businnsand Profewbm Coae)orthathebexemptthemfromand
the boas for the alleged exemption. Any violation of Section 7071.5 by any OUTLE TCHESFI%TURES
applicant fora permit wbjms the applicant to a civil penalty of not morethan
c Rve hundred doll..(SM. NEW ESIDEN77ALELECTR
l,asownerofthe ro SQ Fr
STORIES TYPE CONSTRUCTION
k P 6 compensation❑ F FrtY.or my employees wltA wage as their sus
,will dothe work and thestructure s not Intended or offered for
O sale(Sec 70th,Business and Profego..Code:The Cmdo'does License Taw
g does not apply to an owner of property who Wilds or improves thereon,and �gQC.GROUP R .UNITS
who doessuchwork him elforthrough hsownemployem,provided that such
Improvements are not intended oroffemd forsale.If,however,thebullding or TOTAL:
Improvementswldwithln oneyearofcomplctiogtheowner-builderwill have
trye�trdeo of proving that he did not build or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEB
LJ L as owner of the property,am exclusively contracting with licensed FLOOD"LONE APN
PERMIT ISSUANCE
contract..to mmtmd the project(Sce.7044,Business and Professions Code:
The Contractor's License Taw doss not apply to an owner of property who
ALTER-DRAIN k VENT-WATER(EA)
coOds t r Improves thereon,and who mnt.m for wN p(ojms with a FEE SUMMARY
ryp]Iamsexempt under
Settothe Contractor's License Law. BACKFLOWPROTECT.DEVICE
LJ 1 am exempt under Sec. B k P C for ms reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT'M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-Insure,ora RECRIPr M
certillcateofWorkers'Compereatl;losuranm ora=rtl(Ied ropymereo((S=. GAS EA.SYSTEM-1 INC.40 5 PARK FEE Y_ N_
3800.Lab C.) /� !� ` D, /-7
�, Poliryp 1, — .� 17 l ! RECmTX
Co any / EA.SYSTEM-0VERd ) B U ILUING DI VI SION FEES
M-ified copy s hereby furnished. EASE/INDUSIRLW INTERCEPTOR PLANCHECKFEE
(� ❑certJea copy s rued wire the sty Int ren div at, .
CERTIFICATE OF ECEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSAN)T -STORMEA.libi Date Rel i 1#
(Thssmion need not be completed lithe permit is for one hundred dollars
(SIW)orlessJWATER I{Fls W/VENT/ELI:CTR ENERGY FEE Y_ N_
1 — imnlfythat in the pedornan<co(thework for which the permitsssued,
KlJ I shalt not employ any person in any runner so as to become subject to the
Workers Compensation Laws of CalB.rns. Date WATIR /TREATIN'G PAID
licant
Z Z NOTICE TO APPLICANT.If,after making the CertBlcateof Exemptien,you NE'W DENTIAL IafMB. SQFr. DRIC Recef t#
O should become subjm to the Workers C.mpersation provsioro of the Labor TOTAL:
fA Code,you must forthwith=reply with such provisions or this permit shall be 13U1 DIN
G FEE
deemed revoked.
W
CONSTRUCTION LENDING AGENCY SEISMIC FEEF
d Thereby orkfor
hatrw there lea=mtruRionlending(Ser. agenry .C) perform TOTAL: ELECTRIC FEE
� Z anrdee.of Name
—rwhkhths perMtsssued(Sec.3097,Cis.C.) PLUMBING FEE
LL O Tenders Name
LL IcndsrsAddrex Tv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I=oft. thatl Iagree to c rcadmsa all
citynand dcounty hat ordinances and
Q. s=rt.ct.Iagrre to comply with all cityand=untyominanmand state taws PERMIT ISSUANCE � PEES PAID:
>. relating butiring
=mtructlon,and herebyauthorlurepreantativeaofthis aVV
I— Z dtyto er Up.nmeaWve- nttoned property for inspection purposes. ALTER OR ADD TO MECH. Dale Receipt#
(W gree to save,In ren and k=p harrelex the City of Cupertino
V gal billtien,pdgme is, sajru nde penan which may in anywayyyyyyaccrue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL:
mei`In cons a of the anti. this permILn�7 AIR HANDLING UNIT(OVER t0,000CFM) CONSTRUCTION TAX
C((((( CONSTRUCTION TAX PAID:
of
.q.. Ap ican/Contractor44 Date E)(FIAUS'r HOOD(W/DUCT
HAZARDOUS MATERIALS DIS RE
Will the applicant or fumm building occupant re handlehazardous HFATING UNIT(TO 100,000 BTU) ----bate Receipt#
nuterul as defined by the Cupertino MurdcipalCode, apter9.lZandthe
Health and Safety Code Section 2553Ha)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes [n No
Will the applicant or future building occupa useequtperentordevim , VENTILATION FAN(SINGLE RESID) , T� ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air �i
. Q.ralityManagement District? BOILER-COMP OHPORl00,000BTU) ,}UL,2.71990
Ej No
haYes ve read the hazy .us materiae requlremens antler Chapter 6.95 of BOILER-COMP(OVFR 100,000BTU)
the California Hmlth k Safety Code,Sections 25505,75533 and 25534. 1
understanathatifthe buildin docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. .FI'
SQ .
r.p flityton.tifythe ant.ft requiremsmswhiehrrwstb ril}t�l} I'}. ClIruifBQ
tante of a Cert k, fOc= aney.
O.vner.....rodzed agent ate (�� ISSUEDBY:�• 6 I7
TOTAL: Iv
�— OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIN PEN ONLY
BuildinA Prowl Identificia
Ion �( /1 PERMIT NO.
Building Address:to 123 Ao.Wt. ti h 'Oy O1 V/1 ` _ , 2 0 4 4 0
Ow
40i4"P
ON
vN o'M1Or) 1m Y -� 1 CITY OF CUPERTIINNO-BUILDING DIVISION A
4� +t�L+ eI c 1. S
ContemmesName: Lie.N.: APPLICATION / PERMIT
BUILDINGnECTR)CA4ML BINGMMC MCAL CATEGORY CONTROL
r. I✓_-��
Archi n En oe _ 7-Ic� d,J
/Ae`NaIO QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
o ao
Address: _ / Q.S/t A W1 PERh9TiSSIJANCE � ❑ ❑ ❑
LIC ENS EDCONlRARO 'S DEC RATION
Ihereby
actkan 7(that)am Rcen3oftheunder simssaprovisions of Cnions odeanenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
it...I I.fon7000)ofdaffect. (thegualnessand Pro(csslonsCodGand my
limnx la in ml roe and effect, PANELS '
Date Clap�LlcN
DateAlyflN I,
-,`�P Con'mrtor 7'ire'y. 7(II TWO AMPS
ARCHITECused.pARATIO OVER10DIAMPS SQ.F7.FLOOR AREA $/SQ.FT.
pQ?�O I understand my phns ahaB be used u public rcmms
E Od E Licensed Professional SIGNS ELECTRICA
fn
Z,
OWNER-BUILDER DECLARATIONg1.EC CIRCUIT {,S-0 O
I„ y IhcrcbyafOrmthat lamvemptfromthe Contractor.License Law(wthe
following reason.(Benton 7Q)1.5,Business and Professions Code:Any 6,or TEMP. POLEVI .
Kcounty which requires a permit to construct,alter,improve,demolbh,orrepalr
y .a anystructum pdortoits becamealsorcquimstheapplimntforsuch pertNt to
a file a signed statement that he b licensed pursuant to the provbions of the POWER
Ou, Contractors License Law(Chapter9(mmmendngwlth5en1on70sfio(Divi-
30�' sion3ofthe Business and Protections Code)orthat he bexemptthere(romand B POOL ELECT VALUATION
H ,� the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWITCHES "[� peyy�
605 applicantfora permit subjects the applicant to a civil penalty of not room thanALIA ,]���-r-ly/t�
five hundred dollars(¢500). NEW RESIDENTIAL EL TR SQ.F7.
�n 0I,as owner of the property,or my employees with wages as their colli STORIES TYPECONSTRUCTION
C compensation,will dothe work and thestructure Is not intended or offered for
OIn(Sec.7040 Business and Professions Code:The Contractors License law
$ don not apply to an owner of property who builds or improves t heron,and OCG GROUT' RES.UNITS
a who does such work Noxi(mrthrough hisown employees,provided that such
Improvements am not intended orof(ered forsale.I(hcu, vvr,the Wlldingn TOTAL:
Improvement Weld within one yearotcomplation,the owner-Wilderwill have
thg*men of Pmmng that he dm not build or Improve for purpose o(sale.). QTY. PLUMBING PERMIT FEE
FLOOD LONE APN
LJ S as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 70"Business and Professions Code: PERMIT ISSUANCE
The Contractor's Lle,nse Law does cot apply to an owner d property who
Wilds or Improves thereon, and who contrens for such pbojens with a ALTER-DRAIN&VENT WATER(EA)
m,➢![+ctorW licensed pursuant to the Contractor's License Law. BACKFUIWPROTECT.DEVICE FEE SUMMARY
IN 1 am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y N
• (Tuner Date RECEIPT p
WOR KMAN COM PFNSATION fcoLA ATION pp(yUgES PER TRAP SCEIOOL TAX Y_ N_
Why affirm that I have•certiBote of conxm Io self-Insure,ora RECEIPT N
rtitl<ate ofWorkers'Compensadmn insurance ora certified copyth mitf(9ec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Wb C.) - O If
PmRcy.—;qU�-L 03 GAS FA.sYsnmE vER6(EA) DINGRECEIV
Com anv "j BUILDING DIVISION Fr.ES
rC-z"Mropybbam furnish.
F-]CariBed copy is filed with the city Inspection division. GREASE/INDUSML WASTE INTERCEPTOR PLANCi-IECK PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPPAID '5-
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI t#
(Thissection need not be completed tithe permit b for one hundred dollars
($100)orless.) WATER HEATER w/VENT/EL@CTR ENERGY FEE Y_ N_
I cem(y that In the performance of the work forwhich this permit Is issued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workc%Compensation Laws of California.Date PAID �I'��q
Z Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
licant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei tJl .7V1`-V
should become subject to the Workers'Comperwtlon provisions of the Labor TOTAL: a
¢
w mCode,you=at(orthwithcomply with such provisions orthis permit shall be BUILDING FE /�.
W deeed revoked.
M 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hercbyat@mthat there is a construction lendingagenry forth.perform, TOTAL: ELECTRIC FEE
M Z ante of the work for which this permit b Issued(Sec.Som,Cw.c.) PLUMBING FEE
Q O Lenders Name
LL F Lenders Address QTy-j MECHANICAL PERMIT FEE MECHANICAL FEE
W I certdythatl have macithlsapplicatlonand statethat theabove Information
O
1 bmrren.Iagma to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlu representatives of this
I" N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
_ 2 Date- Receiptq
(We)agree to save,Indemnl(y an d krep harmless the City o(Cupe Urtino
AIR HANDLING UNIT(TO 10.000 CFM)agaWtlbbNues,pd ts,mpsand expenses which may in anywayaccom.rue SUBTOTAL:
against w1 I nence
of the granting of this permit.
AIR HANDLING UNIT(OVER 1p"CI I) CONSTRUCTION TAX
ignsmreo pplinn Contractor iDate IXHAUST HODD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALSDASCLOSURE
Willtheapplies u
nt orfume building occupant store or handle hamous HEATING UNIT(TO 100,WO BTU) Date Recel tit
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
I ealth and Safety Code Section 25532(a)2 HEATING UMT(OVER 100,000 BTU) TOTAL:
Yes M No VENTILATION FAN(SINGLE REs1D) ISSUANCE DATE
Will the applicant or future building occupant uequipment or devices
which emit haeamous air contamlm rats as defined by the Bay Area Air.
Quality Management Dixtrict? BOILER-COMP PER'OR I W,IXID BTU)
hyes ave mad the havrZNaratenab requirements under Chapter 6.95 of BOILER-COMP(OVM 100,00)BTU)
the Califrola Health&Safety Code,Sections 25505,25533 and 25534.1 I
understand that if the building does not corrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT.
rexponsibility to notify the occupant of the requirements which most be met 't JL lOi g 'gCl'
prior to issuance of a Certificate of Occupancy. u yt t'A
Owner or authorimd agent Date �ISSUED
TOTAL: Y1�J\Z'U'
OFFICE COPY