21320 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project mentlH<atmnPEKMITNO.
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Building Address: l0-2,IS 21320
_ ��j3 1d, u.ML-F
Enron. APPLICA ITON SUBMITTAL DATE
CITY OF CUPERTINO-BUILDING DIVISION lo—.L.�4,6
ContrattoraName ue.No: APPLICATION If PERMIT
T F^O GFOYS -rNC BU DINGELFCTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
Arc d/En,8�neer. Lie.Na:
-C f-CP O QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ® 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ion7O that O)of Di lonsedheunder BuM mandsoffe& ponr9(commmc AI'PLIANCESRESIDENTIAL JOB DESCRIPTION
IngwllhSet1on700Wot d offeon3ofthe Bus+nessand Prolesslomrde,and ory 5`IP_&Folly r
Bane"in fuss{9Im and fret. rANFvs �C15HB-1h �.3P<.'¢IRr16
License Clan_(,�_Lk.N (
ate Co DTC`pS DECPRATION yam tK,
ARCHITECTS DECLARATION IOW AMPS
�Z I understand my planss1uB W used pe public recoOVrds. OVER 1000 AMPS SQ.F7.FLOOR AREA 5/SQ.FT.
OSIGNS ELECTRICAL
Licensed Professional
Q w OWNER-BUILDER DECLARATION
In FA SPECIAL CIRCNT/MLSC
'i„ Z (hereby a�firm'hat lam exempt from the Comrators License Law for the
M followingre .(Setlon 7MIS,Business and Prefasions Code:My dty or O Z�.., TEMP.METLR OR('OLE(NST.
countywhich mgrto It permute,mrorequireath,Impmvent fors ch,ormit to
PIM5�¢ anya suture priostatement
shat he is abensed pursuant
to the formions of It a POWER DEVICES
llie a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law f(Dapter9(commencing with Section 7000)ofDivi. SWI SONG POOL ELECTRIC VALUATION
O sion3ofthe Businessand Prot lape Code)orthathe Isexem there(romand
ay.' the bz,hor fthe alleged exempllon. Any violation o(Se tlont70315 by any OUTLETSSWI FIXTi)ftFS
0Oapplicant fora permit subjedstheappllcanitoadvll penalty of est morcthan "2.000 —�
n, �e five hundred dollars%5M. NEW ALELECTR SQFF. SIOMLs TYPECONSIRIICTION
❑I,as owner of the property,or my employees with wages as their sole
�7Q compensation,wllldothework andthestmcture bnotintended or offered for
D vale(Sec.7016 Business and Professions Code:The Contractors License Law
doesnotapplytoan owner of property who Wilds orimproveathereon,and OCC.GROUP RFS UNITS
whodoessuchworkhmxlrorth=gh hisownemployces,pmv+ded thatwch
Improvememsare not Intended oroffered for sale.IL however thebuilding or 'TAL:
Improvement hsoidwithin oneyearofsompltlon,the owner-builderwill have
ttr�urden of proving that he did not Wild or Improve for purpose of wleJ. QTY. BING PERMIT FEE FLOOD ZINE APN
u L as owner of the property,am exclusively mntratlng with..coned pFRMRISSUAN
mntratmss to construct the project(See.7066,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-
NTactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FE
E SUMMARY
112E"I'S
RYLj I am exempt under Sec. B k P C for this reason
Owner Date
DRAINS FLOOR ROOF,AREA,CIOND. ANITARY Y_ N_
RECEIPT s
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
. I hereby affirm that I have a o rd icate of consent to self-insure ora RECEIPT p
certificate ofWorkers'Compensation Insurance ma cerdfied copythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
.✓ 3800,Lab C.) RECEIPT
Policy M GAS EA.SYSTEM-OVER d(FA)
Com any BUILDINGDI VISION FEf:S
ECertlfied copy is hereby furnished. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
E]CenJied copy b filed with the city W impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET. Date ReceI tlt
(Thlssetloo need not be completed Rthe perodt b forone hundred dollars
(SIMerloo.) WATER BEATER W/VEM/ELECTR ENERGY FEE Y_ N_
I certify that In the perfomunerof the work for which W s permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
O Applicant Date Remi ted
2 NEW RESIDENTIAL PLMB. SQFI'.
Z 0 NOTICETO become PLyet tot IffteeWorrers'Co perhis Ction preo(ons oft eLyou
shwldoefurthtto the ply with
Cuch prwtlonprovhis peofthe Labor TOTAL:
� W Core,youeked.rthwith comply with such provIslope arthIs permit ah' be BUILDING F 5loo
dremed revoked.
W � CONSTRUCTION LENDING AGENCY SEISMIC FEE
a (] I herebyafnrmthatthere is a construction leadiagagenq(orthe perform ELECTRIC FEE
7 Zare'.fthe work forwhlchthis permit Is Issued(Sec.30WCIv.C3 TOTAL:
U O lander'a Name PLUMBING FEE
LL h- Lender,Addmaa QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O W Icertilythat I haveread that appllodanand state thatthe above Information
IL bmt.rrel agree to comply with all cityand county ordinances and state laws PERMR :
LSSUANCE FEES PAID
>. relating tobulldmilemoUutlon,and herebyauthorlrercpresentativesoflhis
F 2 city to enter upon the alovo-mentioned property for inspection purposes. ALTERORADDTOMECH.
CWe)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
V
against llablllties,judgments,costs and expenses which may In anywayacvue AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL:
against aid me...equen I a grantinged this permit.
AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
/� !e ! 2" !!1 "13 "9U CONSTRUCTION TAX PAID
Signa ao7 Appiimt/Contractor Date EXHAUST HOOD(W/DUCT)
HA]A R DOUS MATERIALS DISCLOSURE
V,. ',he applicant or future building occupant store or handle havardoos HEATING UNIT GO 100,ODO BTU) Date ReCel to
materiai, defined by the Cupertino Municipal Code,Chapter 9.17,and the II �
Hcalthana_-afety Code Setion2553](a)i HEATING UNIT(OVER 1W000 BTU) TOTAL: `L) t
❑Yes - ri No
Will the applic at orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazrrdc r alr mnlaM"nlsasdeflped bythe Bay Area Alr per{
Quality Mawgcmentl"sttt7 es BOILER-COMP OHP OR 100,000 BTU( -JUD,
4Yes Li No
lave read the h ons maI riala reqularrcnts under Chapter 6.95 of BOILER-COMP(OVER IW,000 BTU) Qnry
the Ca) u4He.hM 0ifety Code,SectiOpe75505,75533 and 25536.1 91g9
tinders d that it the buildP&Iu not currently have a tenant,that It is my NEW RFSIDENTIAL MECH. SQ.IT. .(per RV �,f J -
prtnutmhduanceof tythe'o' panto the requlrcments which must be rrM 111�(/
prior m Lssuana d aCeniflfate of Occupancy.
Owner or authodred agent Data TOTAL: ISSUED BY:
OFFICE COPY