19876 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEIUOTNO.
Building Address: 19 8 7 6
Oovc\ — L
n ante. hone: A A
CZE C CITY OF CUPERTINO-BUILDING DIVISION
CpptnRre Na It'd5Lk.Nt APPLICATION I PERMIT - -2-
O
` 0Iu1 BLT -CMCAL-MUMBING•MECHANICAL CALORY CONTROL
• A Ilett/Engineer. Lie.Nor
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Q r '3 C) IC PERMIT i' - ,$ .&-BUILDING PERMIT INFOiyar„""'
Ad reit �^� PFRMITMUANCE (
LICENSED CONTRACTORS DECLARATION El El
I hereby Alfbmthat l enlicenaed underprevWonsof Chapter9(rommenc AMJANCES-RESIDENTIAL BDESCRB'T10
Ingwlth Section700D)oi Dlvlsion3ofthe Bus andPmfenionsCode,andm
Ilmnx Is In foUjit.and effe t. 'r v�yy �1 PANELS
Llan C11- Lice SIJ / I (T �t .—�f•
Date2
- _aContrstar — 1LUP TO 200 AMPS
ARCHITECT'S DECLARATION 1014000 AMPS
q�+neOp ZI understand my plam shall be used w public records. OVER1000AMPS SQ.FT.FLOOR AREA S/5Q.FT.
C Z
t;�NoLer n ed ProfessionalSIGNS E GL
OWNER-BUILDER DECLARATION SPECIALCR
o. I M1ereby a(0rm that I am exempt from the Commtors Linme Law fm the
ZOtZ`� followingreason.(Section7015,Bualmosand Professions Code:Mycityor E ST.
FF' cvuntywhichrequlrnapermittommtu caler,lmpt ,demllsh,orrepair
g, < a nystmmmprimtalb Wuame,al mquWtheappBontfmau&permitlo pD CBS
ps O U file a signed statement that he is licensed pursuant to the proWlom of the
03 tp� Contractor's License Law(Chapter9(commencing with Seton 70W)of DIN- NG ELE
1„rs, aion3ofthe Businnsand Professlona Code)arthat hebexempttherefromandCmk\a VALUATION
<-O
the basis for the alleged esemprlan. My vlolatlon of Seton 78715 by any
applicant fore permit aubjets the appllcanito a civil penalty alone rorethan I)qMEkSMTC4S"T
flue undred dollars(SIM. REgm AL ELEC STORIES TYPE CONSTRUCTION.. �I,as owner of the Property,or my employees with wag-as theirwle
Zp mmpemafIon,will do the work,and the couture isnot(meMed cur offend for
CO
.1.(Set.7044,Buslmnsand Pmfe-ism Cade:The CaMntors Uterus law
$ da-not apply to an owner of property who builds or improv-therrcn,and OCC.GROUP RES.UNITSwhodonauchworkhbrueBmlhmagM1 hisownemployen,provldedthatach 2'{t�
impronurr re nor Intended oroffered for sale.If,however,the building re TOTAL
Improvement b eoldwithlnomyearafcompldloMtheawner-Wllderw0I have _
tlgikunlenof provi.gthathedid nm WWorimpmvefmpurpoaeo( is.).
QTY. ..!"ti i.:PL NG'P IT _)'� FEE:r
LJ L as owner of the property,am eachulvely contracting with IloemM F7.00D TDNE MN
conmton to conatmtthe project(See 7034,Bualnnaandprofe-ionsCade: D
The Contntors License Law don nor apply to an owner d Property who ALTER-DRAIN&VENT-WKTEK(EA)
builds or Improves theeon,and who rodrata for ouch pto)ecta with a
�gBf�ator(s)licensed pursuant to the Contntora License Law. .,.a' ..,.no C FEE SUMMARY::'�`,;,)r-��,)4.�
LJ I am exempt under Sec. B&PC for this reason BACK FLOW PROTECT.DEVICE
Owner Data DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEB'T/
❑I Fenby el(Irm that I have a certificate of consent to uB-loon,m a �S.��P SCHOOL TAX Y N
• mni0oteafWorken'CompensationlnauranmmaartRiedaopythemfOec. REGEB'T•
3800,Lab CJ CAS EA.SYSIIM-LING OIIILbIb PARK FEE Y_ N_ ,
Policy F RECFR'T N
C. any G'4 EA.'SYSTEM-0VER4(EA) BUILDING DIVISION FEES
MCertlfted copy is hereby Liml.hed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
MCertlRed copy b filed with the city inspection division.
CERTIFICATE OF F7 EMPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-SANRARY-STORM EA.200FT. Dat¢ Revel tic
(ThIsaetton need norbe completed if the permit is(mora hundred dollars
MOD)mIeri WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Imni(ythat N the performance of thework forwhich this Permit Is Issued,
I shag not employ any Person lo any manner n.to become e,r6je�to the WATER SYSTEM/TREATING
Worken'Comppp� sotlonLa (Gllfomla.Djte er;P,] PAID
O Z Applicant I-F��•�at NEW RESIDENTIAL P[.MB. :Q.FT. Date Repel t#
Z O
NOT,
ICANT:ll,after ma—king this Certlflote of Eaemptnn you
Fshould become aubjett to the Workeri Comperuxbn prosialom of the Labor TOTAL:
N Code,you resat forthwith comply with sucA provisioner or Nb permit shall be
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a � lhombyafRmlhat them paconstruction iendingagency for the perform, ELECTRIC FEE L
M Z anmaftheworkforwhlchthb oriented permit oried(Sm309/,CIv.CJ TOTAL
U O [.Mae.Name r ,: .i PLUMBING FEE
U. h 1<nder.Aaa-. d4.,:MECFiA1IICA_I,PfiRMIT FEE g MECHANICAL FEE
O Wl bconoetlfythatlhavereadthsappll-tbnaMYatethatthea einfornutlon
a et.I agreeto comply with all city and county ordinam nand orate laws PERMIT ISSUANCE FEES PAID:
>. m
W rdatinglobullding construction,and hereby authorise mientativ-ofthb
H Z city to enter upon the above-mentloned property for lmpenim purposes. ALTERORADDTOMECH. Date Rxei tR
_ (We)agree to save,indemnify an d keep harmlem the City of Cupertino AIR HANDLING IINR(TO against liabilities,jadgments,omemand expenses which may In any way acme SUBTOTAL:
.glom sold City In conseque.of this granting of this permit.
AIR xANDUNc uNrr(OVER 1a,DDocEH) CONSTRUCTION TAX
Signature of Apptiosnt/Contrsctm Date EXHAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO I OO,ODO BM Date Reeei tF
material-defined by the Cupertino Municipal Code,Chapter 9.11,and the
HeAth ami Safety Code Section 25531(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yon - r]No
Wllltheappliant orfutum Wilding occupant use equipment or devices VENTILATION FAN(SINGLE READ) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District] BOILER-COMP OHPOR 100,000 BTU)
4Yen ❑No
hawereadthehuardommaterialsrequimmentsunderChipterG95e( BOTLER-COMP(OVER 100,WOBTU)
the Califomla Health&Safety Code,Setlom2550S,25S33and25534.1 NEW R[5IDENITAL MECH. SQF7.
understand that If the building don not currently have a tenant,that It la my 1
responsibility to not ify the oro pant of themqulnmenis which moat be met
prior to Isuanre of a Certificate of Ompa my. a Oy
Owner or aulho trod agent Data ISSUED BY: "•� � W-9"
TOTAL:
OFFICE COPY