21049 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Profs Identification PERMITNO,
Building Address: BLrr�1 D I O 21049
W mr� ama: 011e:
I oVl 1T:4- CITY OF CUPERTINO-BUILDINGDIVISIONq
2 �
° tractor'.Name: Lm•No: APPLICATION I PERMIT I �J
kcl FiG ILO S�-ZICATEGORY CONTROL#
Ar7rih1itlen/Engineer, -..�:�..aal1���� Ie No: BUILDINGET.ECTRICALPLUMBINGMEGHAMCAL
uLa&*-S QTY ELECTRIC PERMIT FEE �rBUILDING PERMIT INFO
Address, G PERMIT ISSUANCE IZ� ___R= UbLi PLUMB MirFr-
4,y K ® K
LIC Rcm C err Woos TION ,y y'' �J
Ihth Sbftl70th)fDivim3ofheSusiwWomofCssions9de,and -` APPLIANCES-RESIDENTIAL R,(no JOB DESCRIPTION
Ingwlth Section 7000°!Dlvffeet. ofthe Bueloeaaand Pro(eanionaCode,and my
licenm is In(u
to Rntra Zi PANELS / ,tea
License Clam LieaT K jjll �I
Date Contactor a1
ARCHITECT'S OE A ON 20]- AMT'S
Oa Zp Iundentaad mypi ..hall be used as public records. OV 1(100 AMT'S SQ.Ff.FLOOR AREA S/SQ.FT.
�6� Licensed Professional I 9 ELECTRICAL `O ^
OWNER-BUILDER DECLARATION �f &LALCIRCUIT/MISGf"
Z. .4 I hereby affirm that l am exempt from the Contractor.License Taw for tha.
0 pp following reason.(Section 7071.5,Bualness and Prof anions CSde:Any city ar 'E •R P
O ZTEMP.MEI'FR OR POLE INST.
p carntywhkh require))pj;c
Snstroct,alter imp e,drmolbli,arrepalr J ,
anystacarepnorto its
lslso requlre.2feapp lantforsuch permit to Y r1'03VERfile a signed indenter,thlrinxd pursuant tothepeavialoluofrthe,O wI. Contractor.License lawr9(commencing with Section)000 of DM-
BOJon3oftheBuslnemendOns Code)orthat hebeumptthere(•rjlt fid SWAIMINC CCTR[C VALUATION
Sn....7777 the basis for the alleged exemption,, Any violation of Sectio 703 by any a B Q
applicant fora permitaubjecte theapplicant to a civil penalty ..tabs. OU7LEISSWI7C FIXTURES
$ five hundred dollars($500). ";1,
C �n I,as owner of the property, my P y %'" RES PMIAL ELEGTR_SQ}7, STORIES TYPECONSIRUCTION
❑ p party,or em 10 eo with wa as their sole
5 compensation,will dothe work,and lAestrunure isnot intend oroffcicit(ore
5 O sale(Sec.7049,Bualneu and]P��rofftunkms Code:The Contract e.Uoejrs>ar�LXW.
�$$ does nal applyto an owner oTpmpertywhobuild'arlmp nthereogland:, OCC.-GROUP RES,UNITS
whodoe such work himself or through hisown emp11. s rovlCed that such
improvements are not intended oroffered forwk!If,how cgtheliulldinga TOTAL: " L
improvement bsoldwllhinoneyearofco ptetlogthe r-bu0derwlllhave
theburden°lprovingthal hedidnMbuildcrlmproveI purposeofmk.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
M L as owner of the property,am exclusively mntr ng with licensed PFRMITISSUANCE
contractors to construct the prefect(Sea 7074,Business and Profe aloru Code:
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT LINTER(Eek)
Wild, or Improve.thereon,and who contaaM1 for ouch p(ojacta with a
�q0.t ceor(s)Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT'DEVICE FEE SUMMARY
LJI am exempt under Sec. B k P C for this reasonOUTSIDE IF
Owner DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N
. Date
WORKMAN COMPENSATION DECLARATION RECEIPT N
pp(TURE&PER TRAP SCTi00L TAX Y N
{iI heaby)(firm that 1 have o certificate of consent to opy tnwa,or RECER'T I,
3800 als afWarke�ln',C,amperwticonlnsuanaora certified ropythertroflSec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
l ry bC.) I -0 ZJ I�J
Poll Y DING DIM
Com an GAS FA.SYSTEN-OVER4(EA)
y� ^� BUILDING DIVISION FEES
�Certlfiedco ere mbhed. 1�-wF' _.Py-s GREASE
WASTE INTERCEPTOR TEA NCHGCK FEE
Certified copy is filed with the city lepred dlvi.loA n.
CERTIFICATE OF FIXEMFT[ON FROM WORKERS' GRFASR TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFT. Date Remi t#
(Thlnnection need not be complcted tithe permit V(Drone hundred dollars
($1I unify that
WATER HEATER W/VENT/ELHCTR ENERGY FEE Y N
Ill not thato the Nnsouiaofthenner an as t bthispermit1.trued, —
I.hall not employ an/person In any runner n m to become eubjecl to the WATER SYSTEM/TREATING
Workers Compenutlon G...(Gllfomla.Data PAID
O Z NOTICE° Date Rerei t#
ZO NOTICEco APPLICANT:If, arkem-fter komNasation pmvuiomofthen,you NLIV RESIDENTIAL PLMB, SQ.FT.
C de yoecomeeubjecimthe p°yk s'Compenaation Tmvbimuofthetabor TOTAL:
LU N Cede,dmv krttorthwlth comply with each proWalons arta.peaNt shall6e Z
7 deemed revoked. BUILDING FEE by LU
GCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affirm that there is a construction iendingagency for the perform
Z ELECTRIC FEE s Q
ance of the work forwhich this permll b issued(Sec 309-/,Clv.CJ TOTAL: �a 1
V O Iander's Name PLUMBING FEE
LL H ender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythatl have read lhasappllcationand state thattheabove information ,,aa.s��'�
ucome.l agree to comply withal)cityand countyordlnancnaand sate laws PERMITISSUANCE IZW FEES PAID:
>. relatinglobuilding construction,and hereby authorize representatives ofthla
F N ty to enter upon the above,mentioned property for Impection purpose. ALTERORADDTOMECH.
Z (We)agree to give,Indemnify and keep harmless the City of Cupertino Date Receipt#
V a gainrtliabillliliuud mens,codaandexpeme.whichmayloanywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againsteld City ro ance of flee. I Ing of lhls permit. J'
�kl� J��� AIR HANDLING II[uTI'(OVER IO,OOgCFM) CONSTRUCTION TAX
�4 641A.,..{/ ''' CONSTRUCTION TAX PAID:
5 nature of cantARDO ctq Date EXHAUST HOOD(W/DUCT) (�'
HA7ARtureb TRIALS DISCLOSURE
Willtheapplics
redrat byreurebuildingomipalCode, hhand1.M1avadthe I-IFATINGUMT(TC31W,000 BTU) Date Recei t#
ureteral as dented by the Cupertino Municipal Code,Chapter 9.17,and the -
F Iealih and Safety Code Section 25537())7 }[EATING UNIT(OVER 100,0W BTU) TOTAL: 1
❑ Yea �h
Will the applicant or mrc building occupant use equipment or d.vices VENTILATION PAN(SINGLE RESID) AUJMFE DATE
which emit hazardous air contaminants as defined by the Bay Area Air 1�'
. Quality Management District? BORER-COMP OM'OR 100,00 BTU)
I-1 Yes rF
ave read the baza o..materials requlrements under Chapter 6.95 of BOILER-COMP(OVERT 00,000 BTU) jE 1 O s7+7
the California Health k Safely Code,Sections 75505,75533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RES[DENTTAL MECH. SQ.FT. ,,L
empoodillity to notify the occupant of the requirements which must be ret Aifs/ (�f ri1QB'II.rA
prior to lanuanceo rt atoofOrou ancy. Go -
Owner or aulhorized gent Dale TOTAL: 10 ISSUED BY: lJ VY1'V1W Vv'�"""N.
OFFICE COPY