20772 APPLICANT TO FILL IN INFORMATION WITHIN RE LINES — USE BALL POINT PEN ONLY
Building Protect Identification K
t I: t n/� PERMIT NO.
Buyyng Addre e !a ` AFP 7 J 20772
1/l.,
CITY OF CUPERTTN0.6UILDING DIVISION //''
co(yer�ctor, L�ie.NNo: APPLICATION / PERMIT !Y-(7-1:? U
BUILDING-ELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lic.Krx
Q'IY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ [1 X
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam Licensed underprovisions of Chapter 9(mmmenc AI'I'LIANCESRESIDPNITAL JOB DESCRIPTION
ingwlth Section7000)of Dwislon3ofthe BuslnestandPm�iona e,and my
licenselslnfu effect. PANELS ���
License Ch® + Ic.N
Date ontnctor,
CHITECIPS DE ON /� 201-1000 AMPS
At z I understand my plans shall be used as public crones. OVFR 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
(/ Lirnnsed Professional SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
�• FnSPECIAL CIRCUIT/MISC
V, Ihereby affirm that latm exempt from the Contrador'sLicenx law for the
pp following reason.(Seatlon 7MIS,Bualness and Professions Code:Any city or
O Z H =ntywTEMP.METER OR POLE INST.
�,4 d anystmhmph orlresaper nceaLnrequ,alter,Unpmve,demw&prrcpalr
C any awned statement hat he LI also eel pursuant t the for visions of t e ppV DEVICES
floe a signed statement that he la licensed pursuant to the tion 70M) of the
�3 Gn3.fthe ucen anw(ChapWmter 9 ommnthathecing eumpnhemfm andivi� SWLV(MINGPOOLELECRC VALUATION
5 lit 5 sion3 of the Bu.,inessand Pro(embro Code)orthat heberemptthercfromand
g M 65 the bash for the a11egM exemption. Any elolnatloof Section 7031.5 by any OUTLETSS'WITCHESFIXTURES
Mlapplicant fora permit subj to the applicant to a civil penalty of not more than
o� five hundred dollars($SM. NEW RESIDENTIAL ELECTR
❑I,as owner of the property, e•'QfT' TYPECONSTRUCTION
p pray,or my employees with wages r their sole
7Q compensation,Businewillclothework,fesslo structure ode:ThrContractor o License
ed for
Low
(y ❑ sole(Sec. ppy to alnowand Proksslore Code:The orimpctots roves thereon Law
s$ whoddoes utapply work owner ofproperty
rough who Wilds oyees,povidMron,and ded that such C.GROLIP RES.UNITS
EE wprovemntsoussuch are not mselfor edorough his own e.If,
the
or
improvements are not intended oroHorca for tale.If, tamer-q the buildingorTOTAL:
Improvement umldwithin oneyearofcompletbgthe owner-bullderwill have
tiAmMen of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
i•T-OODTDNE APN
Lj L as owner of the property,am exclusively contracting with hosed
PERMIT ISSUANCE
contnadon to construct the project(Sec.70K Business and Professions Code:
That Contractor's License Law does net apply to an owner of property who ALTER-DRAIN B:VENT-WATER(EA)
Wilds or Improves thcecon,and who contracts for such plojem with a
cottfTactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under See B k P C for this reasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N __Owner Date— RECEIPTN
WORKAN COMPENSATION DECLARATION FIXRES PER TRAP SCI TAX Y_ NN
❑I hereM .fI1
by affirm that I have a ceM1iB<ate of tenant to ael4maure,ora RECEIPT N
certificate of Workrrs'Comperaatloo Insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab
II N p
Com any GAS EA.SYSTFAI-0OVER BUILDING DING DIDIVISION Fr.CS
oCeM1lfird mpybhercby furnished. REASEIINDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V f0ed with tM dty
CERTIFICATE OF i](EM PFION FROM WOR KERS' GREASE TRAP PAID
Q COMPENSATION INSURANCE SEWER-SANTFARY-STORM EA 200FI' Date Recti of
Rhyne cion neN not be completed If the pertNt is forone hundred dollars
($]W)ort..) WATER HFn.I.eR W/vpxl./Ed.ECTR ENERGY FEE Y_ N_
1V_ I wrtifythat in the performance ofthe work forwhich this Permit is issued,
`� I shall not empl any pe on In y manner m as to become subject to 1M
Workxri Com n n ova of, II r> � WATER SYSTEM/TREATING PAID
O ApPll<ant Date Recei t#
Z NEW RESIDENTIAL PCMB. SQFT.
Z O NOTICE TO Ila to king th Certificate of Exempllon,you
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must fort hwith comply with such provisions or this permit shall be 6UI DING FEE
5; deemed revoked.
U — CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L I herebyaffirmthzt there eacom uctlon lendingagency forth perform ELECTRIC FEE
7 Zaroc.ftho work forwhichthis permit is Issued(Sec.3097,Cie.C.) TOTAL:
U O Lenders Name PLUMBING FEE
Lender•.naarrss QTY. MECHANICAL PERMIT FEE
LL t-O W Icedlfythatihvereadthbapplicatlonandstatethattheaboveln(omation MECHANICAL FEE -D
a horned.I agree to comply with all city,and county ordlnancosand state laws ( PERMIT ISSUANCE _pD FEES PAID:
Y relating to building construction,and hereby authorize representatives ofthls
I— Ncityto teruponth above-mentioned property for inspection purposes. AL=ORADDTOMECH.
Z agree to save, dermally a d keep harmiess the City of Cupertino Date Receipt#
V gal labilitlea,pd e,ostsa expense which may in anywayaccme AIR HANDLING IJMT RO 10,000 CFM) SUBTOTAL: O
Bald City in ceo( anti of this permit.
% /.1 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date PxBAusr xooD(w/Duca — CONSTRUCTION TAX PAID:
HAZARDOUS MAT[RIALS CLO URE
Will the applicant or future building ecoopantstore o hndlehazardous BEATING UNIT(TO 100,000 BTI) Date Receipt#
rruterial as defined by the Cupertino Munidpal Code, apter9.lZandthe 1s
I frallh and Safety Code Sectio ? HEATING UNIT(OVER 100,M BTU) TOTAL: �vU
❑Yes I�
Will the applicant or future bu ilding occupant use equipment or devices VENTILATION FAN ISINGLE RESID) ISSUANCE DATE
which emit hares rdous air contaminants as defined by the Bay Area Air y kUBdf
. Quality Management District? BOILER-COMP OI IT OR 100,0W BTU)
(1 Yes Q❑w No ('(I
4have read thehuarclous materlah requirements sneer Gaplot 6.95 of BOILER-COMP(OVD2100,000 BTV) „ ( 159
the Caldomla Health#Sof Code,Sectlov 25505,25533 and 75534.I •.t
unde t red that ifthe but n d='rotcurrcntly have a tenant,that it Ismy NEW RESIDENTIAL MECH. SQ.F7.
resp bilityronati4"A
yt pant oft crequirementswhichmust met City et Cunertino
rl l LssuarlC'c of a C< 1 0/0 ancy.
9 i-7
Reror autho agent Data TOTAL YO ISSUEDBY:
OFFICE COPY