21091 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulldingi a' s + 210 91
Qn Ills Or
s ams: one: APPLICA77MMMM7rAT=A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT LO-R-qb
hitect/Engineer. Lic.No: BUILDINGELECnUCAL-FLUMBING-MFOHAMCAL CATEGORY CONIROLa
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
LICENSED CONTRACTOR'S DECLARATION PFRMITISSUANCE 1:1 ❑ El tYl
IMhSyl.lrmthat lam Bemsed under heBugrovbioneofCha.t,Commmmc APPLIANCES JOB DESCRIPTION
Ing seh I,I.
license b In fu farce and etre<. !(! C-.1 /_ PANELS }
License 11 Lie.p «� Z
1 n
nate Contractor fLhq
ARCHITECTS DECLARATION AMPS
0b Iunderstand myplamshallbeusedaspubllcrecnrds. DO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
d Licensed Pmfe Moral LECTRICAL
G
6 OWNER-BUILDER DECLARATION CIRCUIT/MIST
1herebyaf@mthat lamexempt fromthe Contractors License Lawfothe
O Z H following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE I
F� cauntywhlch requires a permit to construct,alter,Improve,dennlish,orrepalr
a anystrucwre prior to its bsuance,alsorequirestheappOsant for such permit to DEVICESfile a signed statement that he b licensed punumt to the provbiona of the Contractor.LicerueLw(Chzpter9(commencingwith Ssosfon70D0)ofDivi- INGIW ECTRICO1 sion3oftheBuanesaandPrf.ionCMe)orthat hebexemptiherefromandVALUAthe basis for the alleged exemption. Any violation of Section 70)15 by any /yapplicantfor a permit•ubjects the applicant to a rnil penalty of not rrorc than S FIFggXTURESAA/c, �i fivehundrddollars(5500). S ENTIALELECTR.�❑I,as owner of the property,or my employees with wages as tMlr sole / - SQ Fr. RIES TYPECONSTRUCTION
k compensation,wdldothework.andthc,t =mbnmintended 50 sledfor ( Dle(Sec.7014,Business and Profxedom Code:The Contractors Lt..Lawr->E does not apply to an owner of property who builds orimprevesthrom ,and / /(��^ whodoeesuchwork himselforthmugh hisownemployees,provided that such -� I I OCC.GRO(/P RES.UNRS
Improvements arc not intended proffered frsale.I(howeveg thebullding orTOTAL:
Impowernant Lssold within oneyezrofcomplmion,theowoer-builderwill have _ ^
t rden of proving that he did not build or improve for purpose of ask.). QTY. L BING,PERMI FEEFLOODZONE APN
Lj L as owner of the property,am exclusively contracting with lire..
coPERMIT ISSUANCE.,
ntractors to construct the project(Sec.70Busmen ro and ProfenioCode: f Xj 11
The Contractor's License law does not apply to an owner of property who AI,TFA-DRADJ&VENT WATER
Wild. or Improves thereon, and who contracts for such ptojects with fEA)
ogetraoh"(s)licensed pursuant to the Contractor's License Law. AC u FEE SUMMARY
LJ I am exempt under Sec. B k P C for this masonz OUTSIDE FEES
BACK FLOW PROTECT.DENTE t%lll
Owner Dae DRAINS FLOOR,ROOF.A "COAD. SAMTARY Y_ N_
y�
WORKMAN COMPENSATION DECLARATION RECEIPT N I hereby affirm that I have a certificate of consent to eel-inwrc,or a }TXNRFSPERTRA!'1 �# SCHOOL TAX Y_ N
drtiRatoofworkers'CoopewRanlreu m"amrtifiedmpythemf(Sec, v RECEIPT If
3800,1ab C.) GAS EA.SYSTE4C4 OUTLETS PARK FEE Y N
Policy If to c.f' ZIO,>'�I — � — RECEIPT p
Com anyy, eRzm GAS-EA • P VER 4(EA) BUILD]NGDI VISION FEES
�Cemiled copy hereby furnished. CREASE il ^USTRL WASTE 11 EPTOR PLANCHECK FEE
F J�Certlled mpy is(i4d with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectionneed n°tbecompleted iftheperMl brm orae hundred dollars SEWER-SAMTARY-S EA. � Date Recei t#
(5100)or len.)
I certify that in the performance of the work for which this permit is Issued, WATERHFATFR /VENT/E.ECTR ENERGY FEE Y_ N_
I shall net employ any person in any nunner so as to become subject to the
Workera'Comperuation Laws of California.Date WATER BY /TREATING PAID
O Z Applicant
Z O NOTICE TO MPLICANT:(f,ahem making this Certl(Irate of Exemption,you NEW ENTIAL PLMB. sQ.FT. Date Recei t#
F —
should become subject to the Workers'Comperuatlon provisions of the Labor TOTAL:
cc — Code,you must forthwith comply with such provisiom or this permit shal l be
W > deemed mocked. BUILDING FEE
CL E CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a mmtructlon lending agency for the perform ELECTRIC FEE
Z anceof the work for which this Permit b banned(Sec.3097,Civ.C.) TOTAL:
(� O Leder.Name PLUMBING FEE
LL h- Lenders Addreae QTY. MECHANICAL PERMIT FEE
O W lceAirythatlhavereadthbapplimtbnandaatethattheaboveinformation MECHANICAL FEE
IL brumR.l agresto comply with all city and county ordinances and state laws PERMITISSUANCE /rZ,U� FEES PAID:
). N
relating to building construction,and herebyauthodzerep,owntativesofthls
F Z citytoenterupon theabovo-mentioned propertyfor inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#'
a gaimthabihtlea,judgments,coasandexpenx whtchmayinanywayac a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said C IL In cons que�myolf/the granting of this permit.
�AfYI/LAAI.diC� I ��.�/ AIR HANDLING UNTT(OVER iQ000CFM) CONSTRUCTION TAX
Signature or Applicant/Co actor �e tZAnNG
OD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardoueT(T010Q000 BTU)material..drilled by the Cupertino M rucipsiCode Chspler9.1$andthe _ Dale Rttei tpHealtY�d Safety CadeseNioon 75533(a)I T(OVER 100,000 BTI!) TOTAL:Will the applirnnt orfuturcbuilding ocmpantuucquipment ordevims FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminantsas defined by the Bay Area AirQu lityMawgcment DisMct7 (3HPOR 100,0W BTU) p��a�I/���p
a, Yes No O ADD
?have read the haza�oaa materiab rcquvementsundcr Chap[er 6.95 of BOILER-COMP(OVER 100,000 BTU)-
ihe Gllrornb 1lwith&Ser lety Code,SMians 25505,25$33 and 15534. I
undc.tandthatlithebuildingdoesnm-,omtlyhays.mranLtbztit ismy NEWRESIDENTIALMECH. SQ.FT -; s 1990
respomfli itytonaify the occupant of the requirements which most be mer
prior to issuance m a Certificate or Omvpancy. -
Owner or authorized agent Date Ply of rflMrtinn
TOTAL: ,QD ISSUED BY:
OFFICE COPY