21655 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building FmIca ldentlfbtlon FERhIlTNO.
HuMingAddrosx,
1.6360 21655
f // a ti/
s DATE
1020 FL �� 7e. CITY OF CUPERTINO-BUILDING DIVISION (—Lw /r' 1 A
Contnctare Name: LNo APPLICATION /PERMIT �`L
7k.5-7q S' Bl1fIDINGELEC[RICAI.I'LIJMBINGMECHANICAI. CATEGORY CONTROL.
ArtM1Bea/Fsgircer. Llc No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PF]thRTI.SSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hembyefirm that l am Beamed under punidmeol Cloipteri?(.c, APPLIANCFSRESIDENTIALBDFSCRETION
ing with Sectbn 70MM Dlvldon 3 of the Budrm and PrefeW«uCode,and my
8a•.nee Is Into andPANELS
Lbeme Claa_(�,f�_Lle.e N I 7 r"__
Dale Cantnctor /_(_///D-at5__ UP TO 200 ANG-S
-
ARCHITECPS DECLARATION AMPS
�z Iunderstand!"plamsha8 be wed as public records OVERIODOAMPS SQ.Fr.FLOOR AREA S/SQ.FI.
[O[
U Lt«rued Pral®bnal SIGNS EIFCIRICAL -
w OWNER-BUILDER DECLARATION
7 rfr' �j IherebyafRmnthat l am e.emptfrom the Cosurader'a Llarue law for the s'F3:uLCQiCUIT/MLSC
QQ 'qpp�
following
reason.(&ctlon MIA Bwbese and Profubns Cade:Any city or
FLF'� countywhlchrequB apemdttowr a,alter,bnpmve,de lbh,ormpalr T4]'T'METFR OR INST.
anyetmmmpr toisbeua«gaborequlrutheappBantfmr apemdtm
K file a d eel deterrent that he b Baneed POWER DEVICES
OV 5 a wnnant to the pro 7DOO) f the
w Contrvdarb License Law(Chapter 9(mmmenWg with Section 700J)of Divi-
t; C.RIC
Oe don 3 of the hundred, eea
and Profma Code)or thatb heexempt therefrom andswfl�POCVALUATION
y.'S the hula for the alleged exemption. My halation of Sectbn 703LS by any
apphant fora pemdt.ubjectstheippllcam too civil penally dna more than OUTLETS
E fiv�e �ndred ddlara(SSM.
�7�n LJ1,as owner of the property,or my employees with wages as their ante NEW�DAWIAL FR SQFr. STORIES TYPECONSIRUCIION
mmpeneatlm,wBlaothe work andthe structure Is not intended or offered for
Osale 6e,7061,Bualruv and Profeesebos Code:The Contractor's Uame Lw
(�js$ don natapptywan owner of property,who bunds orlmprwesthereon,and OCC.GROU1, RFS.UNITS
0.0. whod«nsuchworkhlmre8 orthrwgh hlsownempinyee,provided that wch
improvconerds am rot intended or offered for sate.If,however,the building or TOTAL:
improvementbwldwithinomyearofc«npldbmtheownerb Werw0lhave
t"mIenofpmvingthathedm riot buua or improve t«purpose oracle.). L NG PER IT FEE
U 1,as owner of the property,am exctwh:ly�trutln6 with Ilrenaed F100D ,NE AM
mntrartwe to mm rud the project(Sin,70K Bwioed and Prdedde.Cade: ISSUANCE
The Contractor's License Law dm nal apply to an owner of property who ,DRAW 4 VENT-WATER )
Wills or Improve m
thereon,and who romema!«such, pwjects with a
cIlatpactor(s)Beemed prrsoani to the Contractors Liana Law. RA rS.
DEVICE, FEE SUMMARY
U I am exempt under Sec B 4 P C for this reninQ1JTSI DE FEES
Owner Date F, SANITARY Y_ N_WOR KMAN COMPENSATION DECLARATION RE�'T a
❑1 herb affirm lit I ha e a«nlBate d am t to self-hoom «a �s SCHOOL I" Y_ N_
anilioteof affirm Comp lutue. Inflect of comet t ropythemof 6ec. RECFBN
3800.Lb C) GAS EA.SYSTEM-1 C O PARK FEE Y_ N
I'dkyl O a Rr=e
Cnm nv _ GASEA.SYS EM7 0 )
;drT7 BUILDING DIVISION FEES
CertNed mpybhertby rwhed. GREASE/INDIISTRL BJEFRCQaroR PLANCHECK FEE
CeuUBad ropy b(fled Mth the cky Irupebbn dfvltlm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCE SEWMS,ANIFARY-SIORM EA X)IIFT Date Remi t#
(1'h1.seNon need
not be camplded Bthe permit b(more hundred doll=
(SIM)arlesJ WATER HEATER w/vFI•IT/ELEcrR ENERGYFEE Y N
I«rtily that in the performance of the work for which ova permit I.Issued,
1 shall not employ any person In any manner no u to become subject to the WATER SYSITbt/TREATING
w«kenf comPw
eatbn laws of CAlfornla.Date PAID
NEW RF3DENTIAL ILM& K,FT.
Applicant
Z = Date . Remi t#
O NOTICET rrx,su ICANthe aflermaHompe owton prewi E.empbn,you
should become subjM b the Walken'Cor�ematbn pmvbbru of the Labor - TOTAL:
~ N Cade,you nw.st forthwW comply with sucb provisions or this perut shell be
W > deemed rewked. UJILDING FEE
CONSTRUMON LENDING AGENCY SEISMIC FEE
1 IhImhyaeBrm thethemist udlon lending agency for the perform ELECTRIC FEE
7 Z ansae the work rorwhkhthb pemdtb Weed bee 3O97,CWTarnL:.c.) PLUMBINGFEE
(� O I<ndcre Narre
LL H Tenser.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertirythe l have read thbapp"tbn and uatethat the Acwe lnforntamn
a bmrrta].Iagreeto comply with Ali city and county oNWnm and satelawe PERMIT ISSUANCE FEES PAID:
} N rtytoent r upongmrutmctlon,and hereby authmU rtprncnpurpo of thb
F Z city(We)
agree
to the alsovnmention If property for Wpe Cit purposes. ALTER OR ADDro MECH. Date Remi t#
V — (We)agree to save,bdenW(y an d keep hamdes the City d Cupertiw
age bCityIadgmew, <apenan whkh Fermhany wvyamue AIR HANDLING UNIT TIO 10,000 CFM) SUBTOTAL:
.gal dClry in roes the granting dtNs pemdt. AIR HANDLING UNIT(OVER 10,000CFT0 - CONSTRUCTIONTAX
ov Bu
orAp nt/Contract« Dee EicKAusr HOOO(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
N
Will the applicant or tutus Wilding osupant store or handle havrdoe, tj HEATWG UNIT CIO 100,000 BTU) Dat
me Recei t#
aterial as defined by the Cupertino Municipal Code,Chapter 9.12 and the _
I Ieilth and SafetyCadea-5,y1m 25537.)1 HEATING UNIT(OVER 100,00)BTU) TOTAL:
T�I Yn I No
IRnet hard a tore Wilding onvpamdby the Kiy raAt, VENTILATION FAN 6WGLE RESID7 1$$ ONCE DATE
which emit luvrdow ab oantamW w a.deRrcd)ry the Bay Area At,
Quality Marugement Wtdcti MOILER-COMP PSB'OR 1 W,IX10 ETU) ,
❑Yea, No J4
7 hove read the M1avmou materials rryulrtmenb under Chapter 695 of BOILER-NMP(OVER 100,000 BTU) �(
the G Womb Health 4 Sa Foy Cade,Sect lora 25505,25533 and 75536.t iv 0Ion, 1
understand that if the building does not currently have.tenant,that It is my NEWRESIDENITALMECH SQFT (V�
mporoibilltyto miry the.pant d the rtquberrcda whkh nwst be and
pd«to Lxownce of a Certificate of Occupancy. �/►.�_ __
Owner or autherrlud agent Date ISSUEDBY:
TOTA4
OFFICE COPY