22729 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIU04T NO.
Building Add rose;
/UG/G 40#,s%e eOj�o ao�. r�PF� r,��0 22729
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ante: a one: A .
E�Jr/11A�CiAUJE /� %n�pwllrj` VY� CITY OF CUPERTINO-BUILDINGDIVISION p ^
16 -
Arthlted/Engineer. Lk No: q�
Contrartru.Nenr GcNo- APPLICATION / PERMIT
BLnLDING-ELECTRICALPLUMBINC MECHANICAL CATEGORY CONTROL M
aid '` /� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:�OO/O /d.4'e 4fiP . G'0Ae7 PERMITISSUANCE ❑ ❑ fist ❑
LICENSED CONTRACTOR'S DECLARATION I�
i Ihereby affirm that l am licensed under provision.of Chapter 9(commou, APPLIANCESRFADENTAL JOB DESCRIPTION
Ing with Section 7000).!Division 3 ofthe Business and ProfessionsCode,and my
nse ce
lile In talirt
foe and effect. PANELS
/
-11...ClassUr-M l//
Date Cormdor 6�z:U
ARCHITECT'S DECLARATION 201-IODO AMPS
0 Z I understand my plans shall be used as publlc records. OVER 1000 AMPB SQ.PT.FLOOR AR f/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL B p
OWNER-BUILDER DECLARATION SPGCALCEtCUIT/MISC 1 'I IL [F—
ze., D IN
l herebyafflrm that l amexempt from the Contractor's Llrense Law for the
Q qqq following mason.(lection 7011.5,Business and Professions Code:Any city ass
0" county which requlresa permittocmutrudm
,alter,Improve,deollah,orrepalr TIME.METER OR POLE[NST.
'4 aoystructumprtorwitsIssuance,alsorequlreslheapphranHorsuchpermitto POWER DEVICES � 9i
RIS file a signed statement that he Is licensed Pursuant to the provisions of the
R$?Ow Contractor's License Law(Chapter 9(commencing with Seaton 7000)of Divi-
"'BOJ elon3 ofthe Business and Profemloro Code)orthat he is exempt therefromSWIMMINGSWIMNG POOL ELECTRIC VALUATIOUF
the basis for the alleged exemption. Any violation of Sedlon 7031.5 by any
a5
applicant fora permit subjects the applicant to a dvll penalty of not more than OUTLE7SSWITCHESFTX7URES ,
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. SPUMES TYPE COh'7RIKTION'
I as owner of the property,or my employees with wages as their sole
HZ_ c mpeneation,willdothework andthestrudure isnot intended or offered for
O sale(See 76N,Buslncas and Proferolons Code.The Contndoes License Law
5$ does rmtapply to an owner of property who builds or improves therein,and OCC.CROIR' RES.UNITS
C: whodomeuchworkhimselfwthrwghhlsownemplaym,provldWthatach
Improvements,are not intended oroffered forage.If,howevep thebullding or TOTAL:
Improvement wldwlthlnaneyearofcomplMbrytheowner-bullderwlll have
the burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
n I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7094,Business and Professions Code: .1
The Contractors License Law does nut apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such p(ojects with a
cgp(Tador(O licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
J LJI am exempt under Seca_____/ B k P C for this meaonOUTSIDEFEES
i1 _/ - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owns , Dale BECF7I'T=
WORKMAN COMPENSATION UECWRATION FDnURF_S PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have o tmum to of consent d pythsure,ora RECEBT N
380,abC.Workeri Compensatlanlnsuranceora certlfled copythere.f l5ee. 1 GAS EA.SYSTEM-1 INCA OUTLETS �. ✓ PARKFFE Y N
PROD,Iib C.) l
Policy DING TM
CAS G.SYSTFAI-0VER 4(EA)
Com any BUILDING DIVISION FEES
OCertified copy b heed with the
city CREASEANDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
❑Cerllfied copy bfliedwith is city Inspection dlvlslon,
CERTIFICATE OF E](EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
Rhbsedlon need not
bs e ENcomSATATId If the permit b for one Funtlred dalton SEWEILSANITARY-STORM R.A.200FT. Date i Recel tM
(91 BE)or less.) WATER F[WTER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of thework f.rwhlch this permit is Issued,
I shall not employ any person In any manner so as to become sabject to the WATER SYSTEM/TREATIN'G
Workers CmnNr,.tlm Laws of Callfomla.Date PAID
O Z Applicant NEW RESIDENTIAL ELMS._SOFT. Date Recei tU
Z NOTICE TO APPLICANT.If,after ma king this Certificate of&emptlon,you
1"- dmuldbecomesub)nt.the Workers'CompensatlanprovltomftheLabor TOTAL:
ir N Code,you=at forthwith comply with such provisions or this permit shall be
LU > deemed revoked. BUILDING FEE
iL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELEL TRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,CIv.C.) TOTAL: '�'-U
00 Lender'.Name PLUMBING FEE $-�
LL f Lmdre.Addmes - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icartlfythat]have readthbappllcationand oidia that theabovelnformotten
O W
1 Is correct.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to Wfiftg consWdlon,and hereby authorize representatives ofthla
U) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date RCCCI fM
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino
agal.st IiabIBlles,judg, ts,costaendexpense vhichnuyleanywayacdse AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL: -p
against said City in cgneequence of thi ant of permit AIRHANDLINGUNIT(OVFRIO,000CEM) CONSTRUCTION TAX
Slgnatum of Appuant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllrant or future Wilding occupant stare or handle hazardous HEATING UNIT(T0100,000 RTS[) Date RCCCI I�
material as defined by the Cupertino Municipal Coda Chapter 9.1 2,and the
Health and SafetyCede�-aSrection 2S532(a)7 HEATING UNIT(OVER 100,000 BTN TOTAL:
❑ Yes I)5 No
Will the applicant orfuture building occupant use equipments devices VENULATION FAN(SINGLE RESID) CSSW\pICE DATE
which emit hazardous air contamloants as defined by the Bay Area Air �1'$'A
Qu a IIIy Management Distrld7 BOILER-COMP(31 N OR 100,000 OTU) �+ ') �IQQ
4hYee No q p 56� A. Ia,71?�
avcreath&SafetyCode, ere ul25505, 5533 an 2 ter.1 ROA.EA-COMP
/ the Californiatand to Health k building
Code, Stela currently
have
a tend,that ]
understandthat
notifylithe the occupant of t ereentiyments which
that it mat NEW RE9 DFN77AL MEIN. SQ.FT.
responsibility
ponslblllty to notify the occupant M the requircmenta which must be met City Of CUp@>'�C'�
dor to leauance of a Certificate ofOccva YM, b G157
Ownerorauth.rizedagent Date ISSUED BA " o k eL
TOTAL:
OFFICE COPY