20386 (2) APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proert Identification - PERMIT NO. .
Building Address: s -
6�4 ° 76A Pr- 2038
ams: rte: - A
CITY OF CUPERTINO-BUILDING DIVISION
' Contractote Name: Llc.No;
APPLICATION / PERMIT U
- BUILDINGELECnUCAI-PLUMBINr—MECIfAMCAL CATEGORY CONTROL Y
ArthitM/Engineer. Lic.No:
QTY ELECTRIC-PERMIT FEE
BUILDING'PERMIT'INFO
Address: PERMITISSUANCE \�
LICENSm'hat ED CONTRAROR'S DECLARATION
I hereection70'hat am.I..3 licensed heunder Busiroviai,m,(Chapter ssions9(rommrn APFf.IANCESRFSIDENML JOB DIESCKIIPITON
Ing with Section forces de felon3oliheBminewandPro(esNoneCode,and rtry -
Lira.. In full force end effect. PANQS /
License Claes Lie.r i p!D AMT'S _ 7+ M1'jF l `ae
Date Contractor [IP TO 700 AMI?S
ARCHITECTS DECLARATION 201.
1000
Zp ta
Iundennd my plane shallbe used as pubilcrernrds. OVER1000AMPS SQ.IT.FLOOR AREA - $/SQ.FT.
Fi Licensed Professional SIGNS ELECTRICAL
GG OWNER-BUILDER DECLARATION SPECIALCEiCU1T/MISE �(',� `{`• T
Lp, IherebyafOrmthatlameaempt frnmthe Contractors LicenseLawforthe
0'2
7following reason.(Ser11on 7031.5,Business and Professions Code:Any city or TEMP.Mum OR E7NSf. -
county which requires a permit to robd
ruu ,alter,Improve,demolish,oreepair
Anystruchtm prior to Its leauance,alsorequimstheappxant forsuch permit to poweRDEV[
CKS
file a signed statement that he Is licensed pursuant to the provisions of the
- 3g� Conine,rs License Law(Chapter 9(rommencing with Section 70M)of Dlvl- SWAMNG
ai.n3.fthe B.Mnewand Pmf.i..Cole)orthathebeaem ihemfm..nd VALUATION
A the basis for the alleged exemption. Any violation o(SIon17m1S by any
666appllart fora perneW
dt subjects theappllcant toal pemlly ofnot more than O ETSSWITC
0 15
<a C
flue hundred dolUteheAO. WEL TYPE CONSTRUC ION
f the property,or my emplayeee with wages r !heir dolece.704imaTbnot intended or offered(or
dile(Sec.et ppy B.toshowami f property Cade:TheC improa rsUeswa Lawdocs oessuclyroan imserofprough his wromeor improovidedreaRandOCC.CROUP RES UNITS
whodoesauchwork Mmtended hrough hleownempthoweprovidedih machimprovementssold within one earo(redforwle.thhower-budebuBdlhave Improvement laeold wlthinoneyear,(compidlon,the owner-bu0derwlll haveIl�urdea of proving that he did not build or Improve for purpose of sale.). QT'Y, FEEFI.00D7ONE APN -
u L as owner of the property,am exclusively contracting with licensed pp(MIT ISBUANCE'
contractors 1,ronaB,d the project(Sec.70K Business and Profesalmu Code:
The Cmdrseorb License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda ,r Improves thereon, and,who rontnda for such p\ojects with a
cgp((actor(s)Immsed pursuant to the Contractors Lice..Law, - 'FEE SUMMARY
I am exempt under Sec. B.&P C for this reason BACK PLOW PROTECT.DEVICE
OUTSIDE FEES
Owncr DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION Y_ N
❑I hereby affirm that I have a mrtiRate,of consent to self-Insure,ora F1X'NI4ES PER?RAI' SCIlOOL IAA RnCE T N
mrdiale o(Workeri Compewtlen Insurance ora certified mpythereof(See GAS EA. PARK
3800,1.b C.) ZA M Y_ N "
. Policy Y _ RECEIPT a
Com CAS EA.SYSTEM-OVER 4(FA)
�any BUILDING DIVISION FEES
CertlBed ropy Is hereby fumiahed. GREASE/INDUSIRL WASTE Error PLANCHECK PGE
Certlfled copy is filed with the city Inspection 11W.Ior.
If ay
{: CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- RM EA.200F'I'. Date Recel t#
Rhlasectlon need n,t be completed If the permit lsfor one hundred dollars
(S1N)orlewa WATER HEA W/VENT/E.ECT-R 2 ENGRGYFEE Y_ N_ s- )YEA
Icenlfythat.in the Person lo.t thsinclausatoework hthiopermitlet.the Issued, \
I shall not employ any person in any manner n w to become subject to the WATER SY /TREATING
Worked Compeneatlon Gwa,(Callf,mb. Data PAID
0 z ApplicaNOTICE
NEW R DENTTAL FIMS._SQFr. Date Reeei tR
Z Q NOTICEco become subject
orkers'Comerartion uleo(ons ofteLyou
SF N Code,you
eubpcito the ply with
Comprovuonprovhisparmhs Labor - TOTAL:
Code,you oket forthwith comply with such proWlov orthb permilshall be
j deemed revoked. BU
LU
CONSTRUCTION LENDING AGENCY r SEISMIC FEE 2-- -Ave
(hereby orkfrwtherebarorstmdion lending 097,agencyCifor the perform 1-�y, ELEC-[•RICFGE2R Lc�o
_ 0 Lea of the work for which this permit Is based(Sec.3097;Civ.C. TOTAL: A
enders Name PLUMBING FEE
(!(!(! F' Lendcr'eAdd..a QTY. MECHANICAL'PER FEG
10 W ,IanifythailhavarcadthieappH.tWnandstatethattheaboveinfomuic. 1^ MECHANICAL FEE
` S bc,rmct.lkgrecto complywith all dtyand rountyordinandreand elate laws PTRMITISSUANCE `((,� FEES PAID;
relating to building construction,and hereby authorize representatives ofthis
,F- Z city to enter upon the above-Mentioned property for Inspection purposes.' ALT IM, OR ADD TO MECH. Lr�
(We)agree to wve indemnify an d keep harmless the City of Cu penin, - - Date Receipt#
agalmtllabllltles,judgment,coelaen apenses whichmaylo.aywayaceme AIR HANDLING UNIT(To I0,000CFM) SUBTOTAL'
gaWt wld 1 In ronuxryen of egan0ng of this permit. -
AIR HANDLINGUNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sign,nunlof AppffcznT/C#K(racfior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7A R DOLS MATER IALS DISC OSUR E'
Will the appllantorfuture building occupant store or handle hamrdous HEATING UMT(TO I MOOUBTW
morrbl as dcflmd by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei tit
Ilea lth a ad Safety Ced inn 75537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 3
n Y. No
r Will the a pplleant or core building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hiss rdous air ronta mlwnt as deRrsd by the Bay Area Air
a lily Management District? BOILEILCOMP MIT OR 100,000 BTU)
•� �
Yes �No - - q
have Californiaeamad the hu r under 1 of RORER-COMP(OVER IN,000 BTU) Vfa 1 Q
the understand
Heat the
Code,Sections25505,25533have
ate and 25534, 1
undenland twtlf the building dose not currently have atenany that lttmy NEW RESIDENTIAL MECH. SQ.Ff. ,
rmponsibilil wAcal(ytheocdipa m
of the Ircenta which must be met j
priortoLss
Zia
Cedlfic c -
Ck
PW aulhorlicd age 'Dat -
' - TOTAL: �` ISSUEU BY:
OFFICE COPY
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