21732 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building Project Identification FERMIT NO.
Building Mdrev:
, L/9-N 3c-'-7— /(776 /;dE 3/zo`." cr, 1-oT �6 21
732
fief, nee.
A A
/.'E'6 0 ,2 D v f CITY OF CUPERTINO-BUILDING DIVISION
Contradora Name: , _ LIc.No: APPLICATION I PERMIT - 2-
BUILDING-ELECTRICALnUMBING-MECHANICAL CATEGORY CONTROL N
ArthlleR/Fsgin«r. Lic.Nu
SEN/?v✓ LAGON BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERMITISSUANCE F rni
LICENSED CONTRACTOR'S DECLARATION �f �J
I hereby affirm that l am licensed under provisions of Chapter 9(mmmere APPLIANCESRESIDENTIM, JOB DP'SItUrHON
Ingwlth Sedloo 7000).!Division 3.fthe Business and PmlesslansCode,and my
1
Lia Is in lull forte and died. PANELS
ee Clas Lk N
Dat V
Date Con[rador UP TO 2DO AL425
ARCHITECTS DECLARATION IDI-1000 AMPS
0wOL Iundcrstand my plan shaBbe used as public retreads. OVER 1fA0 AMPS
SQ.FT.FLOOR AREA $/e.4.FT.
V 5 Licensed Pmleviurul SIGNS ELECTRICAL
<. OWNER-BUILDER DECLARATION 3q
SPECIAL C]RC[R ,7
T/MISC
L., 7 Ihcreby a/Ormthatlam exemptfromthe Cont factors Lkenae hwl.r the
0O " following recon.(Section 7m15,Busines and Pro(eslona Cade:Any dry or SG.3
FZFE'� TEMP.
county which requlrnaperMttomnstmd,alter,lmprove,demolish,ormpair METFR ORIOLE INS!.
OO
anystmt mptortolb Wuance,abornryimtheappllantforsuchpermtto POWER DEVICES '
_COO file a signed statement that he is,licensed pursuant to the provlslorit of the
04 Conlradors License Law(Chapter9(mmmendngwith Section 7000)ofDlvl-
�''130C' sion3olthe Butlnnsand Profesbrs C.de)orthathebevm themfmmand SWIMMING POOL ELECTRIC VALUATION
the Wb for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCH1S17D TURFS p /
y <� five hundred apermlb5(s)). the app0canttoa tivll pevlty.fnd more than �•S O C% 'S
c.- O flue i,as
ddhrehepr.
q I,as owner of the m NEW RESIDENTIAL ELECIA SQ.I7. STORIES TYPE CONSIRLrTION
EI �n property,or my employees with wages a Ter sole
2M
compensation,will dothe work, esshmand the aCde:TheCtintended tritcleoitere Law
�p sok(Sec. pply to ainownerf property
Cobuilds Contradora Llecve Law
$$
does not apply roan owner ofpropughhis buildsthethat such
- OCGGROUI' RIS.IRJRS
who does such
nts am not Intelf ndedoroughedowre.If,ho eyerthe building
Improvements ithindedor.ofcm plea .th.h however alder ilI have TOTAL:
i Improvement beald wlthinoneyearofcwnpletbrytheownerbullderwlll have
t rden of proving that he did rot bund or Improve for purpoee of sale.). QTY. PLUMBING PERMIT FEE
LJ L as owner or the roe FLOOD ZONE APN
property,project
am ettK Basi contenting with licensed PERMIT ISSUANCE
contractorsct contend the project(Sec app! to an o and Pf pro ore Cale:
The Contractor's improves;
License Lw dace not apply to contracts,f owner of property who ALTER-DRAW&VENT-WATER(EA)
elluae.r Improve tpursuant and who ader'srice seL p.oj[ab with a FEE SUMMARY
m dor(sexempt under Sm
the ContradoraLicenr Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec B &P C for this reason
DRAINS FLOCK ROOF,AREA,ODND. SANITARY Y_ N
Owner Date RECET T N
WORKMAN COMPENSATION DECLARATION
❑ P SDTOOL TAX Y N_
I hereby affirrn that 1 have a certifiate or consent to vl4lnsum,oFpCIUItFrr PER TRAP RECEU NN
certifiate.(Workers'Compensation Insurance or a ceriffied copy thereof(Sec.
3800,Lab C.) GAS E.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
I,.)ley N GAFA.SYSII2c1-OVER I RECEIPT a
Com any / S (G) BUILDING DTVI 51 ON FE I
Cetifled copy b hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCI'IECK FEE
RCertified copy b(fled with the city Inspection division.
CERTIFICATE OF D(EMITION FROM WORKERS. GREASE TRAP PAID'
URA
COMPENSATION INSURANCE SEWER-SANITARY STORM EA.2WFT. Date Receipt*S.s�
(I'M1lseetlon neN fiat be comps TI the SURA b(.forehundred dollen
C$lW)or lay.) WATFRHATERw/VENT/ELECTR ENERGYFEE Y N
I mitlfy that In the pedomunce of the work forwhlch this permit is Issued, —
1 shall not employ any person In any manner se as to become subject to the WATER SYSIFAL/TREATING
Wcnkori Compensation Laws of California.Date PAID
SII O Z NOTICApplicaE
NEW RESIDENTIAL PINS. SQ17. Date Remi t#
Z0 shoTICETOAP[LICAtothe aRermaHompesationipro of FxempteLyou
should become subject come Workers'C.mpewtlon proWl.m.fths Labor TOTAL:
Q y Code,you must forthwith comply with such provisloru or this permit shall be BUILDING PE'
W > deemke
ed revod.
CONSTRUCTION LENDING AGENCY SEISMIC FEE o
CL IherebyaffirmtI tthembammtrodlonkedingagenayf.rthepedorm ELECTRIC FEE
Z arm of the work for which this per t b issued(Sec,3097,Civ.C.) TOTAL:
O lenders NaI ,�., PLUMBING FEE p, 3
LL H tenaert naareee QTY. MECHANICAL PERMIT FEE
LL me CAFE3
l certify that i have read thbappll tion and statethat theabove Information H
O W MECHANIL
Iscorred.lagemlocomplywlth aril etyand courtyordinandii,ed state laws PERMIT ISSUANCE FEES
} W construction,to building consation,and hereby authorde mprtsentatives of this /y'a. rdis
F. mW
U) city to enter upon the above-mentioned property for petlon purpoan. ALTFRORADDMMECH. DatC. ReCCI t#
(We)agree to save,Indemnify an d keep harmles the City of Cupertino P
V against liabilities,Judgments,cots and expenses which may In anyway accrue AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
agalnat vW ty 1n consequence.!the granting of thle pe It - G
A 7,�—t—L 1� d q I AIRHANDLING UNn(OVER 10,l CFC() CONSTRUCTION TAX 3 2 .p
Signature of Apllcant/Contras. to EKHAUSTHOOD(W/DUCT) CON TR CTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS RE (y _JoyncL
Will theappBantor fumm building odupant store or handle hazardousHEATING UNIT CTO 100,000 BT ) Date RCCCI t#
1 materlil as defined bythe Cupertino Munidpai Coda Ch2pter9.12 and the
Health and Stdy Code Section 75532(a)r HEATING UNIT COVER 100,000 BTtn TOTAL: O S,
❑Yes M No
Wllltheapplkant orfutum buildingoaupaot use equipment ordevics VENTILATION FAN(SINGLE RES[D) ISSUANCE DATE
which emit havrdous air dmumbunts as defined by the Bay Area All >1�alsgy�
Quality Management DbtritT BOILER COMP OHP OR I00,0M RTN *LAO,
❑Yes n No
(have mad the hoz 9ma materials requirements under Chapter 6.95 of BOILER COMP 100,!1(10 BTU) { � ',qq
the California I I.Ith&Safety Cade,Sections 25505,25533 and 25534. 1 �iLln y 1s�s7�
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ7T.
resp.mlbllitytonmilythe.cmpantoltherequirementswichmuatbe met - -
prior to isuance a!a Certificate of Odupanry. rV �!eFne
l.lCI
Owner or author red agent --`-- � Date _ OTAL: ISSUED BYw�s �
OFFICE COPY