21870 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification 7 PERMIT NO.
" 166 t 21870
From:
x
CITY OF CUPERTINO-BUILDING DNISION
Ix,No APPLICATION I PERMIT
W BUILDINGELBCTRICALPLUMBINGMF LAICAL CATEGORY CONTROL
Arehaect/Fsgineer, LIB Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: ( PEIMTISSUANCE .C)r> ❑ ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcemed under pro Eamm of Chapter 9(comeen APPLIANC6RESIDENML gDE9CRf1'IT
Ing with Section 700D)of Dividers a 3 ofthe Busi naand Profestera Code,and ,
ON
Ibemae�b in iou inns and effect. rANFIs
Date n ClaLaic a
nate Gonaanor
ARCHITECTS DECLARATION 201-1000
K Z I urdentaM my plana ahaB be used as public rtmrds. OVER 1000 AMPS SQ.E7.FLOOR AREA 9/9�.FT.
OO.
��j Lfocnsed Pmfembrul SIGNS iY�mrat
6 Gk7' OWNER-BUILDER DECLARATION SPECIALCIRCNT/MISC
7p, Z Iheneby.ffirm that l am exempt from the Contranor'n License Uw for the a
following nem.(Section 70015,Bunnes erd Pro(mbretOudr,Any d y or TEIA
F `i-. muntywhl req Wcaa PemJ[toromc Malter,lmpm ,demolbh,orrepair P.MEITROR POLE INSf.
q� anyatrutlun imor to Iter ieat.l.lao require theapplicam forauch permit to
L U flier a signed statement that he U lloenned pursuant to the pmWiom of the POWER DEVICFS -
�0 (2untnd-e-Lkeme Law(Chapter 9(commenctng whh Section 7000)of Divi- gWp1MING 7K)pL p.ECT.RIt
Oa alon3 of the Business and Pmfmbru Code)or that he la eeempt the¢fromaM VALUATION
F6Jo5 •1
the bash for the alleged exemption. Any violation of Section 70715 by any
eppllcantfor a Peilt aibjecta theapplicant to a civil penalty of not mon than �D-�' tt"}�''FlX[i1RE5
m
O five hundred ddlarn(y500).
Fj1,as owner of the property,or my employeea with wages aa their sok N EW RmDEMIA!'E7•E<'iR SQ.FT, STORIES TYPE CONSIRIX:TION'
comperuatiou,wBldothe work,and thestructure In not Intended or offered for
$ O .1e5ec.7044,Buatrea and Profeeslom Code:The Contractor'.IJ¢Me Law
ogdon e not apply to an owner of property who buiWz or Improvthereon,and
G who dm ach work hMmlfor thwgh his own employee,provided that each OCC.GROUP RFS UNITS�x
Imprwemema ue atlntendedproffered faruse.Khowever,theWtUingor TOTAL: I LJJ
Improv Ml,saldw hlnomyearofcmiple NtheownerbullderwWlove
enofpnving thatheeta at wed ortmprove fe W'P°ss of ssk.). QTY. PLUMBING PERMIT FEE
as owner of the property,am exchatvely rentractbg with Beamed FLOOD ZONE APN
t to criamuct the pmject(See-70K Realness and Profeabe Cade: PERMIT ISSUANCE
Ciml.ctori LI¢nae Law does not apply to an owner d property who ALTER-DRAIN 4 VENT-WATER(EA)
beOda or Improve thereon,and who contracts f¢stl
such p(ojes with a
coNT+ctar(UBeemedp--"b the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_J I am exempt under Sec B 4 P C for this reavin
e
DRAINS FLOOROF,ROAREA,GOND. SANITARY Y_ N Owner Date RECEIVE
WORKMAN COMPENSATION DECLARATION F��S PER TRAP SCHOOL.TAX Y_ N
❑1 hereby affirm that I have• I nento of conaent m copy
ora RECEIPT g
¢ndtb of Worken'Compemuatlan Imuunn¢or.¢rtlfkd copytherto((Sec.
3800,LabC) GAS EA.SYSTEM-1 WC.40I1TLE15 PARK FEE Y N_
PoiCom, GAS EA.Sy5rEM-0VER4(EA) DENG DIV
EY BUILDING DI VISION FEES
Cer"Bed copy l,heed with
GREASE/INDUSIRL WASTES INTERCEPTOR PLANCHECK FEE
�Certllied ropy l,(Lied with the Illy Inspection dfvWan.
CERTHTUTE OF E( MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCEgE SANFl.ARY���m�I. Date Recel t#
(fhls section need eat be completed Bthe perm8
later ala hundred dollars
(1100I¢ks.) WATER HEA'T'ER W/VENT/ELECTR ENERGY FEE Y N
Leen thanamp inthe peeoffiao(th nen iorwMehthis pematl,l,.sed, —
I nhaB not empby any penan b any manner at ss to become ubj Y to the WATER 52,5141/,IRFATING
O Amlke�Campewunn Laws of Gllfamb. Date PAID
Z No T7CETOAPPIACANT:R,aBerreldngthb CeriGteo emptlon,ya NEW RmDFxaAL PLMB. SQFT. Date Reoei t#
shald become subject to the Wotan'Compewtbn provisions of theLabor TOTAL:
CC 41 Co yamatforthwfthmmplywlthw&pmwbmorthhpermN ilhe
> deemed revoked. BVILDINC FEE
W G CONSTRUCTION LENDING AGENCY ISMIC FE
CL (hereby affirm that there U a mmtnction kmding agency for the perform L
= ane of the work for which this permit In tsnued Ger. ,Civ.C.) TOTAL: ELECTRIC FEESo
O Larder.Name PLUMBING FEE
LL F Iender'.Aildens QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtitytlut I hair read thleappllatbn and nate that theabove lNormation hnS ceee,logreetocomplywhhaUctyadc ntyodinanma dotatelaws PERMIT ISSUANCE FEEPAID:
>- N Mating to building conetmctlm,and hereby authmire repreaenbtive of this
F = citytomterupontheabovcmentbedpmopertyfor Wpectbnpupoan, ALTERORADDTOMICH.
(We)agree to save,Indemnify an d keep harmless the City of Q pertlno Date Recei t#
V .g.I.bab04les,jadgmeNa,matnand expa..whkh mayb anywayacv;n AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agahut d City N consequence of the gra d a Permit,
AIR HANDLING UNIT(OVER I Q=GEM) CONSTRUCTION TAX
'genn o(Ap eant/Cmtnetor r Dat a124 4 FIDIAUS'r HODD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplla ore futunbu0dingeavpantstomorha Mlehawdas HEAT1?GUN1T(TOl00,D00BTU)
Date Recd t#
raterlai ae detinet by the Cupertla MuNtlpal Code,Ch.pter 9.17,and the �-
He.1thuid SafetyCode SHon255320)1 HrATWG UNIT(OVER 100,000 BM [7 TOTAL: l kL
Tit Ye NO
Rl the applicant¢ tun heading occupant one equipment or devices VENTILATION FAN(SINGLE RESTD) ISSUANCE DATE
which emit has Maus air contaminant...&[nerd by the Bay Area Air ��®
QvalityeMamagement Deetchn? _ BOTER-COMP DM'OR 100,0.00 BTU)
I Y I—I No
have read the hon oesm,,erial,nqulnmena under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU)
the ���
CaUf.Ulle.Uhk Safety CWd ,Senbm25505,2m513and25534. I ail lYA
unaentand that lithe building don not currently have a tenant,that It N my NEW RESIDENTIAL NQCH. SQF7,
mapovlbility to notify the ottvpant of the rcqulrtmena which nun be met
priortoluuaocedaCerti(Iate.(O.P.racy. o-+u�pw':n10•�a
Owner or authorlud agent Date
TOTAL ISSUED BY:
OFFICE COPY