24258 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ert Identification PERMIT
BalldIng waam,,: 24258
�rote• .scot. ane
CITY OF CUPERTINO-BUILDING DIVISION 1�
Contact °� _ Lk.Nm . APPLICATION / PERMIT. .2-�q Z
el1ILDIN ,L CTRICA4ILIJMBING-�NICAL CATEGORY CONTROL
Arehted/Engtroem Llc No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Add er PERMITIS5UANCE ❑ ❑ [!W E]LICEND CONTRACTORS DECLARATION
( Ihrrclry SEdfl tlutlamlceruedurderpuvbimnof CAapter9(mmmenc AI'PIIAN RFODENTIAL JOB DESCRIPTION
ingwith Sedfon7000)af DMMoo 3ofthe Bualressand Professi.e.Cade, deny
is to fol(orae and df PANELS
Lice. lass &p% u, W
Llcunsc CLb.t
Date Contador
ARCHITECT'S DECLARATION 701-1000AMPS
I 02 I understand my plans sball be used n public records. OVER I WO AMS SQ.FT.11ODR AREA f/SQ.Fr.
O
Ary �j Lboued Professional - SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SpEC(pLCDiCU1T/MLSC
Iherebyafinothatlamexempt fromthe Contractor's Lns
l¢ e Lawf¢the
SS�� pppp❑ fallowing reason.(S�¢I 9m15,Bathes and Professions Calc Any city or
emu my which rNu Ina,a permit tomrutruG,albr,Impmse,demolish,or repair TFMP.ME(TR ORPOLE INST.
any strucw¢prbr to tta buarce,a bo requires the applicant for such permit to
K fib a signed statement that he b ll¢nsed pu.t to the provisions of the POWER DEVICES _
/µµ/..��O ww��•• Contractor's License law(Chapter 9(mmmendng whit,Section 900M of Divl-
F,3oJ SWIMMING R]IX,ELECTRICsbn3 ofthe Businms
and PmfebroCode)orthat he h exempt therefromand VALUATION
P,.Q.•�]] the basis for the alleged exemption. Any vitiation of Scdbn 9015 by any OVILE.ISSl4I7CHESFlX7lJRF5
f5d appM..tfor.permX.vb}ds the applicant to a dvll penalty iced more than
� IQs iye area dollars 0500). SQ.FT. STORIES TYPECONSTRUCTION
j A �QT as ownu of the pro",or m y employees with wagesas theirsob NEW RESIDENTIAL EI.Ff.-iR
7� mlr�4- hs,tbn,wind o the work°nd the drudum b rml Wended or offered for
❑ (Sec 9044,Buslresa and Profesbro Code.TM Contntlors W¢me law
don nossuehto anoose ufthroug ywhobulldaorimpmvntkreoRand OCC.GROUP RM UNITS
E impwho ale nhamMinteldaorwghwowle.lfhm,pmthebuviched haleger
Impuvement aw not Intended oroUereniple b.If,howevegthebu Mve TOTAL:
Mpuverrcntbeold wUhinorcyearo(c¢rspletbn,thewvner4aullderwW love
tIc.)Vrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMITFEE
U S as owner of the property,am exclusively centraetirg with Ilmrued FLOOD ZONE APN
mntruel.to construct the Project(Sec.90W,Busand Profeselons Code: l PERMIT ISSUANCE 1
The Contractor's License law does not appy to an owner of property who ALTERDRAIN&VENT-WATER ffN
Wilds or improves thereon,and.wW mntam for sueh mutts with a - FEE SUMMARY
�W[+doK.I licensed pursuant to the Contractor's Uterus Law. BACK FLOW PROTECT.DEVICE
1_11 am exempt under Sec B 6 P C for tui reason
OU`fSlDF FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N—
Owner Date RECOPI',
fWOR K MAN COMP ENSATION DECLARATION PDCU PER TRAP SCIdOOI.TAX Y - N_
❑I hereby affirm that I have a¢rtlfhte of consent to saB-Inure,¢a RECEII'I.Y
¢nllcate of Worken'ComperaaHon lrsuran¢¢a¢rtBfM copy thereof 6ea.
l GAS EA.SYSTEM-1 INC4 OIf;. PARKFFE Y_ N
Polk lab CJ
Col GAS EA.SYSfQ.I-0V A(EA) DINGRECEDIVISION
Cam y BUILDING DIVISION FEES
f IeertBbd copy is herebywith tlenea. GRFASEANDUSIR1.WASTE INTERCEPTOR PLANCHECK FEE .
CMIEed copy b filed with the mY IropMbn division.
CERTIFICATE OF E(ENPTION FROM WORKERS I GRFA.SEIRAP PAID
COMPENSATION INSURANCE sEwEg-SANITARY-SIO%M EA 70�T DaIC RCoei t#
it
( ectbn need mat Mcomplded lilts permit bf¢oro hundred Bolan
sIOOJorlorIesa.) ENERGYFEE Y—
' N_
I¢rttfyttit lothe pedorrnsn¢of the w¢k torwNN WspenNt is KvM, WATER Fff.ATFR W/VENT/F]LC7R
1 shall not employ any person In any manner so as to bemme msbkat to the WATER SYS[FM/TREATING
workeri Compensadon laws of California.Date PAID
C• Z Appleant - - NEW RFSDFiVTLV.PLMB. �.FI'. Date Recti tit
Z O NOTICETO APPLICANT:If,°fler ma king tui Certu4ateaf Fxmpbbn.you
should bemnc subFct m the Workers'Compereatlan prov6bnsof the Labor TOTAL
F N Code,you rount forthwith meopy with such provlelons ortw perms shall be
deemed rooked. IN
W , CONSTRUCTION LENDING AGENCY SEISMIC FEE'
M eof the work
forw then is mnsbu hented Sm agencyfon the pedomm
Z an¢afinewarie ranwhkbtw permdtbi>,ved(Bee W,Civ.c) - L: ELECTRIC FEE
(,) O lenders wme - PLUMBING FEE
U. 1— lender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O IU 1¢rUfythelhave¢adtwapplatbnandatatethattheabovelnfomatims
bcomoei.lagnetocmnplywW°Rdty°rdmunyord nm° dstatelaws PERMrr ISSUANCE FEF';PAID:
} N rtlatim toboddingeonsumetter,and herebyauthadre repreaentattveofthh -
F Z ely toenterupon the abovcmenlarcd property for inspection purposes. ALTERORADDTOMECH.
V — (Vale)agree to save,indemnify an d keep hamNess the City of Cupertino Date Recci tit
against llabWdeajudgments"..nd expenses whish may In anyw.ya.. AIR HANDLING UNIT(IT310,000CFM)
against we cry mxuequen¢af the gcaNing artw coni SUBTOTAL•
14 9 AIRIiANDLINGINIT(OVIRIC,000CFM) CONSTRUCTION TAX
51 Applont/ on - - ` IXFIAISf HOOD(4V/DIICD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALSDISC URE
WRl the applant¢future Wldbgomspant xo or handle bavni¢u HEATING UMT(N 100,000 BT1n
mDate Recti [N
ut l as defined by the Cupertlw Murddpal Code,Chapter9.1Z and the
Health and Safety Cade Section 75537b)9 HEATING UNIT(OVER 1W,"BTU) TOTA
TYn No
ithe applanu¢ lure Wildtngomrpart use equipment orcf k VENTILATION FAN(SINGLE RFSD) ISSUANCE DATE
whish leoft ha:amlou.air mntaMnant°ae defined by the Bay Area Air B� pp
Quality Management Dbtrlet7 BDILFR-CVM H 0HPOR 100,0(0 BTU) 11' I D
( 4 Yes I�N.
have read the bars oos materials requirements underChapter 6.95 of BOILER-CDM(OVER100,000 BTtn ��� ��
n
1 the Callomla Health&Safety Code,Sectiom 25505,]5533and 75534.I '1992understand that i(tbul
hedingdoesnwtcu enty hsve.ten.m,thatltbmy NEWRFSIDFMULMECH. SQ1T sJ7
respuns3lity to notify the ocanpant of the requi¢ments whish mut be and -
priortoinuanceofaCertl(Icateof Oeospancy. Cllr VY VYf lfllll
Owner oramhadred agem Date ]"BY:
TOTAL
OFFICE COPY