20524 (2) APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
Building Praia 17F.-Ii atlon PERMIT NO.
B.Uding Address: 20524
w rs a one: - ,
CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: APPLICATION / PERMIT R
Architect glneer. Lk.No: BUILDINGELECTRICA4ML BINGMFGHANICAL CATEGORY CONTROL M
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addien 7
PFRMITISSUANCE PLUMB sli�"
❑ ❑
UCENSF.DCONTRACFOR' ECLARATION
I hereby affirm that l am licensed under provlsiov of Chapter 9(commost APPLIANCESRESMENML JOB DESCRIPTION
Ingwith Section 7000)0(Dividoo3 ofthe Buslnessand Pro/essionsCode,and my
license Is in full and affect. ' I PANELS
License Gla Lk.X f W L�pO�J
Dale Contractor [y-iUP TOM AH�S
ARCHITECPS DECLARATION 201-1000 AMPS
MZ I understand my plans shall be used as public records. OVER 1000 AMPS AR $/SQ_'Fp.
q�y O11
k U�j Licensed Professional R SIGNS ELECTRICAL X..
< IN
Qw OWNER-BUILDER DECLARATION {•`�
In �3 SPECIALCIiCUIT/MLSC
t.., owing hereby r of@m that l am 31.5,B fro ess a Com ftogios License LawAny cit or 4
o OF� following reason.(Section 7Qi1.5,Business and ProfesslonsCWe:Any city or TEMP.METERORPOLE INST. I 0
�pp@ rountywhkhrequi apemttommtru"ter,impmve,demolbh,ormpair
y S.c anyslructore prlorto its issuance,also requlresthe applicant forsuch permit to POWER DEVICES
m G7 file a signed statement that he Is licensed pursuant to the provisions of the
Off' Contractors License law(Cha er9(mnurcncln with�1n R w SWIMMING POOL FI.ECIRIC VALUATION a
on3ofthe Busineatand Pransf.ioCodem)mthat he is exetherefromand .!�
the basis for the alleged exemption. Any violation of Sectio7031.5 by any OUTTBTSSWITCIiESFIXTURFS d O6 s��
applicant m
ntfor.pedtsuatl
bjeciatheapylicanitovil perultyof not moretan
h
five hundred dollars(SM. NEW RESIDENTIAL� ELECTR_SQFp. STORIES TYPECONSIRUCTION j ❑1,as owner of the property,or my employees with wages as their sole'
c t
ompensation,will dothe work EM andthestruclure nIntended or offered for
5 ❑ sale(Sec.7044,Business and Profession Code:The Co ttraetofs Lt..Taw
NYE does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who docssuch work himself orthrough his own employees,provided that such
improvements are not Intended mattered formic.If,howeveq thebullding or TOTAL:
Improvement is sold within oneyearofoompletion,the owner-W llderwill have
thp-4urden of proving that he did not Wild or improve for purpose otsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I_J L as owner of the property,am exclusively=trading with licensed ppRMITISSUANCE
contractors to construct the project(Sec.70K Business and Profenlov Code: ,,
The Contractors License Law does not apply to an owner a property who ALTER-DRAIN&VENT-WATER(FA) ,
Wilds or Improves thereon, and who contracts for such ptota jecwith a - FEE SUMMARY `
o9a([aamW licensed pursuant to the Contractor's License Law. BACK FlAWPROTECT.DEVICE
U I am exempt under Sec. n
B k P C far this reaso
"ITSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY 'Y N_
Owner Date re or a
RECEIPT a
W—
M '
WAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mi0am
rtte of consent self-inau FDOURF_S PER TRAP SCI 1001,TAX Y NRECEIPT X
ceniBate
ied
f W
orkers'Comprtloniuranora ifpythe ((Sec. GAE .SYSM-1 CAOUTS PAREY_ N_
RFLmPIX
PlryabCq�z
Co��m rrenv C e. GAS EA.SYSTGI-0OVER BUILDING DIVISION FEES
Certi�p' by Is GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
9
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESETVER-SANITARY-SIORMEA30m,-1. Date Reeei I# ,
(This section need net be completed lithe permit Isfor one hundred dollars
(SIM)or less.) WATERIiEATFRW/VENT/ELECTR - ENERGY FEE Y_ N_
I certlfythat in the performance of the work for which this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
WmkerA Compensation laws of California.Date PAID
O Applicant Date Recei t#
Z NEW RESfOFNHAl['IMI. SQ.FI'.
Z O NOTICE beo MPLICANTa,after making'Com a sationCertifkateo(Exemptof he Lyou.
shoul,you at fort ct to withce Work en'Campevvisins orthiavrmit s Lab be TOTAL:
F N deemedumuat(orthwlth comply with such provisions orchis permit shall be BUILDING ••E
jeeemeareeuked.
W — CONSTRUCTION LENDING AGENCY � SEISMIC FEE
CL I hereby afflrrethat there V a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ante of the work for which this permit is lasued(Ser.3097,Civ,C.)
V PLUMBING FEE
O lender's Name
LL H Lender'a Addresa - - '. QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
OW
Icertifythatlluve rcadthb appBatbnand watcthat lheabove Information
11 bc'orrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE 1 FEES PAID:
>. CL tobulldingronstroction,and hereby authorize representativesofthis
W cltyto enterupon the above-mentioned property for inspection purposes. ALTER ORADDTO MECH.
Z (We)agree to save,hWemsify an d keep harrtdea the City of Cupertino Date' Receipt#
V against liabilities,judgment;costsand axpae.whkh maylnanywayacerue AIRHANDLfNGUNfT(TOIOpWCFM) SUBTOTAL:
alnst ac of the granting of this permt. CONSTRUCTION TAX
AIR FIANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor D,ite EXHAUST I IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant orfuture building occupant store or handle hazardous' HFATING UNIT OO IM,000 BTU), - Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
I lealth and Safety Code Section M33(a)? HEATING UNIT(OVM 100,000 BTU) TOTAL: 1
❑Yes MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RF-%D), - ISSU,�NJMTE
which emit hazardous air contaminants as defined by the Bay Arca Air
4 Quality Management District? BOILER-COMPOtIPOR 100,000 BTU)
❑Yn 1' No I J; p 61990
Ihavcread the haz.Q us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Calffomis Health h Safety Code,Sectlov 75505,75533 and 75534. I'
uMemtand that if the building does not currently have a tenant,that it is my - NEW RESIDENTIAL MECH. SQ.1•T.
mipoesibilily to notify the occupant of the requirements which must be met _ �P;ja of Cupertino
prior to issuance of a Certificate of Occupancy. .� X�..,.���' ��
Ownerorauthorimd a gent Data TOTAL: ISSUED BY;Vw ) \El\1`w/-- 1.
V
OFFICE COPY