24260 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT N2
4 2 6 0
But ldin&Address; r
1� VLi
s aces; p�jr one:
P ° o a 3a CITY OF CUPERTINO-BUILDING DIVISION
Cam'-,r',N.me: b.Na: APPLICATION 1 PERMIT
—. BUILDINGp3,ECTRICALPL ING•MUC NICAL CATEGORY CONTROL
Architect/Engiruer. Lk.Na.
✓ PERMIT FEE BUILDING PERMIT INFO
QTY ELEC
Address: PERMITI A
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions o(Chapter 9(commenc MFWHDE OBD ���
ingwlthSCcllon700D)ofDivlelan3 aftheBuslnnsandProfenionsCode,and my 2x��
Ilcena le In full force and effect.
Licca,ClanN
lc-
L
Date,_C.,ra,c
ARCHITECTS DECLARATION 701-1
flz lunderstand my plane shallbe used apublicrecomw OVER On tPS RIN $/SQ.FT.
Ed Licensed Professional 9GN5 ELECTRICAL f1,,�� ^
< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC f,� I K
Ihereby a(OrmtOWNE exemp-BUIL ER DECLARATION
Llrenu Gw(or the YY R, ••
09
p following reaan.(Section 7031.5,Business and PmfenWns Code:Any city or Pg county which requlroapermit torona
construct,alter,Improve,demoWh,orrepair TEMP.METEROR POLE INST.
any dtmctre uprior to its ledua nce,also regi.thea pp0cart for such perrmt to POWER DEVICES
O Ole a signed statement that he is licensed pursuant to the provisions of the
Contractoes License Law(Chapter 9(commencing with Section 70M)of Divi-
3oe+ Won 3 ofthe Budinenand Profeulon Code)arthat he is exempt therefromand SWIMMING POOL ELECTRIC VALUATIC 1
•]] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWI7C7-IFSFIXIVRFS f/V/19c)
O
< appBcanlforaperMtsubjectslhaappllcanitoadWlpemltyofnctmomlhan
five hundred
owner ars ofthe I0). NEW RESIDENTIAL ELFDTR SQ.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees in with wage. r herr dole
compcnatlon,Busi the work,and thesCd.:Thnm Intended oroffered for
O doe(Sec.ot apply
to dhow end Profession Cod e:The Contractors Llcene law
Q don uc*5u loan owner ofpropertyhis o buildnemporimproovided con,that and OCC.GROUP RES,UNITS
whodonsuch work hMnBodorwgh hieowne,If,ho eprovidedthatach
Improvement are not Intended oro((ercd(orale.I(,own.,r,lhebulWi have
improvement beold within onyearofromPtailors,Iheowner-bullderwlll have
enof proving that he did nm bUiEr Improve for purpose of dale.). QTY. PLUMBING PERMIT FEE FLOODZDNE APN
ad owner of the property,am exclusively contracting with licensed
ro noon to roe. act the project(Sec.70K Business and Profession Code: PERMIT ISSUANCE t
Contractors License Law does oat apply to an owner of Property who ALTER-DRAIN&VENT-WATER mA)
Wilds or Improve.thereon, and who contracts for such ptojem with a FEE SUMMARY
cgpj(actm(e)IkenrW pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICELI I am exempt under See a
B k P C for this rean
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N�
Date RECEIPT M
WORKMAN COMPENSATION fonexa to HXIURFSPERTRAP r� SCHOOLTAX Y N
❑1 hereby affirm that I haves certificate of.cnemis to epythrm. ora RECE'T N
MOD,I.bC. orkers'Compenatlonlrourance oraartl(kM copythereo((Sec. GAS EA.SYSTF7d-1 LICA OUTLETS PARK FEE Y N
pant,lab C3
panty
CoaEA.SYSIEM-OVER4 CIA)
n GAS
Y BUILDDINGINGDIVISION FEES
Certified copy is herebyfamished,the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is flied with the city Impaction division.
CERTIFICATE OF O(EMPTION FROM WORKERS' CRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SMRM F.A.200FT Date Recei tN
(This section need not be completed if the permit Is(Drone hundred dollars
(S100)arless.) WATER HEATERW/VENT/n cr'I.R ENERGYFEE Y N
Ill not employthat in an performanceperson
Inany annex sa as to b co permit b to theed, — —
I shall not employ any person In any manner a m to become ablest to the
Worlicn'Compenutlon Laws al GWATER SYSTEM/TREATINGllfomia.Date PAID
Z Applicant NEWRESIDENTIALPI.MB._ IT. Date Recei t(1
Z O NOTICE TO APPLICANT:IL aaer mildng ht Certificaleof Exempllon,you SQ'
H should become subject to the Workers'Compewtin provision of the Labor TOTAL:
f/7 Code,you at forthwith comply wltheuch provblon or this permit shall be
LU > deemed revoked. LDING FEE Cl assar
aa CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a construction lending agency for the perforb W309T �• ELECTRIC FEE
ance of the work for which this permit ued(Sar. 7,Cl,Civ.C.)
U O lenders Name PLUMBING FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have readthisapplicatlnnand ltalethatthe above Information
iscorrect.I agree to comply with all city and county ordinances and slate laws PERMIT ISSU
1 ANCE � FEES PAID:
} relating to building comtrocilon,and herebyauthorlu representatives of this
f. Z city to enter upon the above-mentioned property for inspection purposed. ALTERORADDTOMECH. DatC RCCCI tic
� — touve,lndemm/yand keep harmless rtino the City of CupeMR UNIT CFO 10,030 CFM)
a sin Ila tles,tudgment,costs and expenses which may in anywayaccrue SUBTOTAL:
again Isald by in consequenre a fl grantingofthispe it.
AIR HANDLING UNIT(OVER 101000 CFM) CONSTRUCTION TAX
S of Appunnl/Coma r t Mist EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS OSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Reeel t#
material tie defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safely Code Section 25532(a)7 HEATING UNIT(OVER ID0,000 BTU) TOTAL:
Yes
No
:llhe applicant orfuture building part use equipment or devices VENTILATION FAN(SINGLE RESID) LkISSUANCE DATE
which a anament air conlaminanletie de0ned bythe Bay Area Alr
Management ament Distrlci7 BOILER-COMP OF4'OR 1DO,O00 BTU)
4 Yea I1 Na
have read the hus ousma/eriab requirement under Cha pier 6.95 of BOILER-COMP(OVER 100,000 RTU)
the California Health k SafetyCode,Stolon 75505,75533 and 25534.1
understand that if the Wilding don not currently have a tenant,that it is my NEW RESIDENTIAL MECFI. SQ.RT
maponibility to ratify the occupant of the requirements lch must be met ��� �� a
Prior to Iesua oce of a Certificate of Occupancy.
Owner or authonnad agent Data ISSUED BY:b - / t
I flat,
OFFICE COPY