22131 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE GALL VUIIN I rcry PMWT NO.
BuOdinI,Protect Identilleatfon 2 2131
Building Addnu:
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ane: �.�e.:.7.y/6 ^ a
L [,�� ZSZ—lJCITY OF CUPERTINO-BUILDING DIVISION
ctce.Name: Lie.No: APPLICATION I PERMIT CATEGORY J CONTROL
• BUILDING-ELECTWCALPLIIMBINGMECHAMCAL
uect neer. Le No: ,t .,. - r.ras^�?rsi' q, t(• -.,,.BUILDING PERMITINFO . .-
"��";ELECTRIC
PERMIT
Add. PERMITISSUANCE h�
LICENSED CONTRACTOR'S DECLARATION API'LIANCFSRF9DENTIAL J"'� JOB DESCRB'IION
Ihareby+f.7DtO).f Di .3ofheBug rov .dpmfeW.sr9(commen PANELS
�� ��
itons,I5ectbn I..afd affeon3ollhe BuYnevand ProlesatonsCode,and
IianY U Cl..I.foil fora and d(ett.
LIanY laL1cN
Date Contractor p)•OWAMPS
ARCHITECTS DECLARATION OVFRIWOAMPB 1 g �QRN 5/SD.Ff.
HOZ I understand my plane shag rtm
be used as public ds. _ _ IU:.., v
OSIGNSELECTRICAL
i Z Licensed ProfeYlonel I �/ T R
OWNER-BUILDER DECLARATION $PF)r1ALCiRCUTT/MLSC 1 a
O 3 Iherebyafm.fSectIamion 31.5,Business
smpt ed Profetor'aL Can :law city or /rrTQ
FQ mntywhich n.6ectaparentusBuatnm+MPropews,ennodAny tltyor 7FMP.METER ORPOLE WSI. Z�
9 muntywhkh aqulmapemdtromnatruct,alter,impme,demolbh,orrtpalr,
any rtrotturt prbrb tthat he
requlrersuant to the Tari permute LOWER DEVICES
Roe•Agnes statement w(Chapter ha 9(cpm pursuant it the provolone f the
II.. son 3f the Licenseurines Lwfeasic C d.)mcing with Section
mialherafof Divl• SWIMh9NG POOL ELECTRIC VALUATION
=0J atebasishaBueaacged Prderbn. Any orthathebeaempnhelSbyrons end OOO `vp
applicant
far the alleged oeta the A Any Wolatbn of na lty o not 15 by any OCL gty }�FDG'URES
+ppBanl fora permit subjem lbs.ppOcantta a civil penalty d rad nnnthan
5 Ove���LyLlrndredid olW+(55001. NEW RESIDENTIAL ELFLIR_SOFT. STORIES TYPE CONSTRUCTION
u owns of the property,or my employes with wages a their sole
c/a�mpenaatlokwilldothe work,andthe atrtacture is not Wended or offered for
p 1 bee 7046,Bu.fmas and Profenlone Cade:The Connectors Llarue law
A�Fdoes not apply to an owner d property who builds or improves thereon and IXC.GROUT' RES.UNITS
who d°asuchwark hlmrtVorthruugh hisawn emplpyea;provided that such TOTAL
Improvemenb are not intended proffered for sale.If,however,thebuflding or
MpmvementisoldwfWnoneyearoirap101 Nth..wn bu0derwBlhave QTY, PLUMB
'PLUMBINGPEI'tWIIT' `1 ':`FEE' FLOODwNe APN
tryepardenofpro ngthahedidwbu0dorfmprovefwpurpo.eofsale.).
L�L as owner of the property,.m auhuNely mntracting with licensed PETIT ISSUANCE
mntnctas to mmtruct the project(Sec.70K Bu.tnm and Profenbne Code:
The Contractor's License law dm not apply to an owner of property who ALTER.DRAW 4 VENT•WATER ffN w•
builds or Improvesre
thereon,and who commits for such pxojects with a t'",'=i'.A„ .,;',FEE SUMMA_RY.... .
cgpl[actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
U I am eaempl under Se B Is P C for this recon SANITARY Y N
DRAIN3E.00R,ROOF,AREA,GOND. RECEIPT a
OwnData
WOR10.fAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TA% Y_ N_
❑I hereby affirm that I have a certificate of consent to selFlnsum,or. RECFII(`
mnifialeofWorkereCompene tionlruuranaoracerUfecDpythere°f(Sec. GNe EA,SYSTpl Li WC40UILIETS 1'ARKFEE R SM
3800,Lab CJ
Policy a GAS.EA.SYSTEM.OVER 4(Et) BUILDING DI VISION FEES
Co aaa�ny PLANCHECK FEE
Certified copy b hereby fumlahed. GREASE/WDUSIRL WABTE WTERCEFTOR
Cert Vied copy is filed with the city inepeodon division.
CERTIFICATE OF EtEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY-STORM EA.2a0RT. Date Recei III
(hissection need no be completed B the permit b for one hundred dollen ENERGYFEE Y_ N_
(5100)m IenJ WATER HEATER W/VENT/E.ECTR
1 certify that to the performance of the work for which this permit Is issued,
I.ball not employ any parson In any norm er n es to become subject to the WATER SYSTEM/TREATING PAID
Workers'Compensation law+of California.Date Date Recei t»
s2 ApplicantNEW RESIDENTIAL PLMIL_SOFT.
O NOITCETO AI'PLICAM:R,+fter making Udo Certt(late a(&emption,you TOTAL:
should become subject tothe Workere''Compenuhn,provisions of the Labor y vo
NCode you moat forthwith comply with such provisions orthls permit shall be I
deer and evoked. SEISMIC FEE
J CONSTRUCTION LENDING AGENCY ELECTRIC FEE
L Thereby afflrenthat them IsmrutruMon lendingagency forthe perlorrn TOTAL:
D Z anaofthe work forwhichlhb permit is Issued(Ser.3097,Clv.CJ PLUMBING FEE
O Led.e.Name QTY; 'MECIiAT11CAL,PERINTT�' FEES`' MECHANICAL FEE
L F Landers Addren 1
W Ioedi"at l have ad thiaapplicadon..dmte that the above Information PERMIT ISSUANCE
FEES PAID:
LU bmrmst.legreeloc0 plywllhall city andmunty0rdinanaserad are law.
N rcI tingtobulWing ,suction,and hereby s.'h.rizenspressmativnafthis ALTER OR ADD TO MECH.
Z city to enter uponn abpvcmentioned property for Inspection purposes. Date Recei tit
(We) eta e, damnify• keep h.rrrdm the City of Cupertino AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
against Wt d a d apenYswh rnaylnanyway...
. chat i `nor be "tin ° Permit. Nf
[� AIR HANDLING Uf(OVER 10,000 CFM) CONSTRUCTION TAX
n '`TSL DaJAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ne of 11 n/Contractor Date
HAZARDOUSM IALSDISCLOSURE HFATINGUNIT(TDIODMOBTU) Date Recel tg
Willt eappbcentafuw.building.pantst°norhandieharardous
materialasdefined by the Cupertlw M.oidpal Code,Chapner9.13,and the HF.kTWGI1NTT(OVER 100,D100,000 BTU)
Health and Safety Codec Stection 25533(47
❑Yea uNo VFNTILATIONFANtSWCLEAESID) ISSUANCE DATE
Will the appilant or future building Occupant use equipment or devices
which emit hazardous ab contaminants as defined by the Bay Area At, BOaER,COMP OLD'OR 100 OM BTU) 6
Quabty Management D'uMtl1 PAID
Yes BOILER-COMP 100,000 OM
4have read the hazy pus
No malmaterialsrequirements under Chapter 4.95 of �1
the California Health k Safety Code,Sections 2550.5,25533 and 2SS34.i
NEW RESIDENTIAL MEt7i.
understand that if the building does not currently have a tenant,that it is my S�.FT.
responfbWly to notify the ocrupaot of the requinmenu which must be mel
prior to Issuance Of a CeYifiam of Oavparuy. (�,1�y--a. "��•�G
Owner or authorized agent Date ,TOTAL: ISSUED BY\^/�
OFFICE COPY