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21039 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Buildin P,ojed Identification PIiWWT NO. goading Address: dOS Phone: 21039 5�- �� � 77.—. nen eros, one: A CITY OF CUPERTINO-BUILDING DIVISION l— Q as N c ic.N.: APPLICATION I PERMIT sk ^I e -+�- K3' BUILDTNGELECRiCAT.PLUMBINr—MBCHANICAL CATEGORY CONTROL N Arohltect/Engineer. Lie.No: '.BUILDING PERMIT INFO +„ to%•' .v<. „k QTYELECTRIC PERM ,r�FEE.i Address PERn0TI%'UANCE �.(� D D LICENSED CONTRACTOR'Sunderprovisions I hereby affirm.70that l+mgcenaedhnS..i vhionaof Chapter9(mmmenc APPLIANCES-RESIDENTIAL J00 DFSCRII'IION inensei In 7000)ofd effect. f1he0uelraesandProfeWonsCode,and my license b In fu1 rose and d/M. PANELS A 1 Lienee Chea LILY W Date Contractor ARCHITECTS DECLARATION 201-1000AMPS �pO I understand my plans shall be used As public records. OVER 1000 AMPS SQ.F7.FLOOR AREA S/SQ.FT. i2 ly Licensed Professional SIGNS ELECTRICAL t C < OWNER-BUILDER DECLARATION r 3 SPECIALCIRCUIT/MISC I hercbyaffirm that I am exempt from the Contractor's License Lw(ass the following reason.Genion 70315,Business and Pnefmima Code:Any city or TFIdP.METFIt OR POLE INSI. county3 Anyamm irhpd.,trequirua perssdetomnstr,q isl t1m.pmve,demsuchormit ir to any manurepdement that heli,Il.emand pursuant in them suchpermitof to POWER DEVICES fila•stgned statement that he b Ilensed punusut ro the provlaions of he Omntor'.Lkense Law(Chapter9(mmmencingwith Section7000)o1'Divi- SWIMMING POOL ELECTRIC VALUATION 05 don3ofthe BuaNss dProfessions Code)orthn heieexempttherefromad she basis for the alleged exemption. Any violation of Section 7MI.S by any OUTLE1SSWITCHESFIXRIRFS r boo © applicant fora permit subjects the applicant to a civil penalty of not rnrethan 11.1 - � /iv hundred dollen(SSW). NEW RESIDENTIAL ELECTR_SQFI'. STORIES TYPE CONSTRUCTION' 7^S R� LjL as owner of the property,or my employees with wages•s their sole compensation,will do the work and the structure b rust Intended or offered for Fp sale(Sec.70K Rustiness and Prefmlone Code:Tho Corued.e.License Lw a'B does not apply to m owner of property who Wilds or imprwn thereon,and �$^ who does suchwork himself orthraughw own employees,provided that Well OCC.GROUP RES.UNITS Improvements are nit intended or offered for sale.If,however,the building or TOTAL: Improvement is sold within one yearofcompletion,the owner-bullderwW have ., IIIL�urden of pmvingthat he did notbuud orimprow rorpurpose of axle.). 'QTY. X-"' PLUMBINGPERMI'F: 21"'s •-%FEE; FLOOD ZONE APN u L as owner of the property,sm exclwively contracting with licensed PERMITISSUANCE aantndon to mnstnn the project(See 70t4,.Bwlness and Professions Code: The Contras or's Lienor Law dm not apply to An owner of property who Wilds or improves thereon,and who mmram for such pRvjeds with A ALTER-DRAIN&VENT-WATER(EA) 1. . c�iranags)licensed pursuant to the Gomosedols Licave Law. `FEESUMMARY',I'.' LJ I am exempt under Sec B&P C for this recon BACK FLOW PROTECT.DEVICE Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. SANITARY RFCEBR M WORKMAN COMPENSATION DECLARATION Of hereby affirm that I have a mdi0oste of consent to seB-0naure,or x FD(TURE4 SCHOOL TAX Y PER TRAP R_ N NM certificate ofWorkeri Compensation luurance ora certified copy them,d(Sac. GAS EA.SYS[EM.1 INC4 OUTLETS PARK FEE Y N 38001Lab C.) — RECEIPT N Polley• S GAEA.SYSTEM-OVER 4(EA) BUILDINGING DI VISION FEES Com any Z. Bled copy Is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE CenlfiAd copy is filed with the city Wpenion division. CERTIFICATE OF EKEMPTION FROM WORKERS• GREA.SETRAP PAID 1 COMPENSATION INSURANCE -SANITARY-SNRM EA III�7 Date R 1# II.�.L+ (This section need net be completed if the permit b rorons hundred dollars (S100)ml..) WATER HFATERW/VENT/E.FLTR ENERGYFEE Y_ _ I ertlfy that N the performane of slat work IorwMch tw peomt Is lasued, I shag nm employ any person ro any canner so u to become mb)ed to the WATER SYSTEM/TREATING PAID Workers'Compensation Laws of California.Date Z Applicant NEW RESIDENTIAL PLMe. SQF[. a esti t# NOTICE TO APPLICANT:It,after nuking/w Card icate of Exemption,you 0 should become subject to the Worken'Compewtlon provisions of the Labor I OTAL: rN Code,you=at forthwith comply with such provisions orthia permits hall be a� lI > deemed revoked. - CONSTRUCFION LENDING AGENCY SEISMIC FEE V SD 1 G Iherebyaffirmthatlhembacolunudlon lending agency for the perform- .ttyT.,w: ELECTRIC FEE 5� 7 Z anm of the workforwhkh this permits lssouni5e 3097,Civ.C.) li ) O I<der'.Name PLUMBING FEE I- Lendee.Add. QTY. -_ C.MECHANICAL-PERMIT"; �� 'FEE, ? W Imditythatlhave readtw Appgcalion and nate that the aboveinformation MECHANICAL FE FCO IL ecumct.lagreetocomplywith all cityand muntyommanesand state law. PERMITISSUANCE FEES Iaft,IQ:, >- N reladngto Wlldleg constmetimend hereby authorize representatives oftw ✓� Z city to enter upon the above-mentioned Property for inspection purposes. ALTERORADDTOMECH. Date R el t# (We)agree to save,Ind emnily an d keep harmless he City of Cu penin •� against babllities,I.dgments,costaand asperses which may ie Any way accrue AIR HANDLING UMT 8010,000 CFM) SUB TAL: against said City In consequent of the granting of this permit. ATR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TA Signature of Applicant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TA PAID: HAZARDOUS MATERIALS DISCLOSURE WBlthe applicant orfuturebullding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTI)) Date ReceI l# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the H,.1thand SafetyCdoSSectime2SS32(a)2 HEATING UNIT(OVER 100,000 BTU TOTA ly W I he applicant or future building omupant use equipment or devices VENTILATION FAN(SINGLE REMD) ISSUANCE DATE which emit luxerdous air roma Mean as defined by the Bay Area Air t• y Quality Management District? BOIL OHP OR 100,000 8'7'!!) Yes No •R. have read the Fav ous materials requirements under Cha pier 6.93 of BOILER-COMP(OVER100,000 BN) Ser, ..t the California Health&Safety Code,Sections 25505,25S33 and 25534. 1 understand that if the building don not camently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr. responsibility to notify the occupy rat of the requirements which at be mss prior to issuance of A Certificate of Occup ncy. Citi' (;r Pf!nnrtlRn Owner or authorized agentDate ISSUED BY� �v TOTAL: OFFICE COPY