24419 (2) APPLICANTTO FILL IN INFORMATION:WITHIN RED LINES — USE-BALL POINT PEN ONLY
Building Project Identification y + PERMIT NO
Build mg Address: r - .r
2,�er 6I C • ' =t�n0 s+ 24419_.
�s nano ams: hone: A A
- b ':// yJ 5CITY OF CUPERTINO-BUILDING DIVISION
Contra Name: • Lic.No:. APPLICATION / PERMIT
BUI D CATEGORY COMIROL N
LING-ELECTRICALPLUMBING MECHA
#CAL t
Architect/Engineer. " '. � ttl Lic:No:
ELECTRICPERIYfIT -.`+ - r 'FEEi t -'-t'':>BU[LDING•P.ERMI'PINFO;t.:
Address: _ - .,•. PERMITISSUANCE . ❑ ❑ ❑'' .
LICENSED CONTRACTOR'S DECLARATION,
•I heeeby a/fbrithat l am licensed under Imm(gons of Chapter 9(common, APPLIANCES-RESIDENTIALJOB DESCRIPTION
ingwlth5 dion7000)of Divlaion3ofthe Buslnemand PrefesslonsC„ode,and my .
It
Lcers(sln full force and effect. PANELS
License Class . LiceNi
Date Contra
dor -
ARCHITECI'SDECLARATION 201-]000 AMIPS
Is Zp Iunderstand nyplare.hallbeused aspubBcrecords. FEA
AMPS' SQ.Ff.FLOOR AREA �k S/SQ.F7.'.
Licensed Professional , ; TRICAL ,I p I�1_ „' l r
6 OWNER-BUILDER DECLARATION .:' �Ig I�n i V
,z p, � I hereby afflrmthat l am exempt from the Contractors License Law for the 2CUIT/MISC rJ na � ^ p�following reason.(Section 7011.5,Business and Professions Code:Any city or O 1'ILl9 16._. A,••[aO H l72ORPOLE INST. ' 'P .."hichrcqulresapemdtmeowtwdaltegimpmvedemolis,hurrep4rnystrLiMmpriortoitslswancgalmrequimatheappllcantforsuchperMtto ICESfile a signed statement that he V Ilcensed pursuant to the provisions of theContractor's License Law(Chapter9(commencing with Section 7000)of Divi- POOL ELECTRICsion3 ofthe Businessead PrefessionsCode)orthat holoezemp[therefromand VALUATION
Q the basis for the alleged exemption. Any violation of Section 7MLS by any II'CHFSFIXTURFS
applicant leas permit subjects the applicant to a civil penalty afro[more than _
rve die'do
llare($500). - NEW RESIDENTIAL ELECTR .
�n (��1yI' d owner of the property,or my employee.with wages as their sole _ "sQFT. '.STORIES TYIPE CONSTRUCTION /•
coo 1'sglon,willclothe work,andthestructom lana intended or offered for
+ le-(Sec.7044,Business end Proless)ors Code:The C.omadofs Llave Law
$ does not apply to an owner of property who builds or improves thereon,andOCC.GROUP RES.[MI75
•
who doessuch work himself orthrough hisown employees,provided that such _
improvereentsare not intended orofferedforsale.If,however,thebulldingor - TOTAL:
improvementlssoldwithlnoneyearofcompletlon,theowner-bullderwiilhave
the I,rden of provingthat he did not build or improve for purpose ofsale.). QY;.+ -` .tPtiLUI�'IBING:PERM1Ttt","A'. ' ";iFEg:' + i--FLOW
—ZONE APN
as owner of the property,am exclusively contrarting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Commences License Law does not apply to an owner of property who
WALTER-DRAIN&VENT-WATER(EA)
ilda or improves thereon, and who contracts for such p
tojech,with at -
%BVador(.)Boomed pursuant to the Contractor's License Law. ' BACK FLOW PROTECT.DEVICE, s t ° ['EEE S[JMMARY i 4
LJ I am exempt under Sec. 'B &P C for this reason
x.
- i!•
' QU I blue ILL
Owner Date DRAINS FLOOR ROOF, SANITARY Y_ N AREA;COND. '
., WORKMAN COMPENSATION DECLARATION' - PRECEPT#
_'QI hereby affirm that I have a certificate of c..W.t to asim.som,or a FIXTURES-PER TRAP SCHOOLTAX Y_ N
certificate of WorkensCompensation Insurance ora certified copy thereof(Sec. RECEIPT#
3800,Lab GAS EA.SYSTEM-1 INCAOUTLECS PARK FEEpolicy a S Y N
Com an ' GAS EA.SYSTCM-0VER4(EA) RECEIPT#
�CY edlfled copy is hereby turalshed. - "HUI LDING DI VISION FE FS
Certified copy is coed with the city inspection division. - GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP. PAID,.
COMPENSATION INSURANCE -
(Ihi.sectimineed not be completed lithe permit isforonchundred dollars SEWER-SANITARY-STORM FA.2Dallr. Date' ReCeI ht
(5]I)0)rtifytJ WATER HEATER W/VENT/ELECTR ENERGY FEE,:' Y
I artily employ
the performs In any he work se,f.as t cern permitsubject
to theed, -
I shall not employ any person in any manner at as to become subject to the WATER SYSTEM/,TREATING
Workers Applicant mpensaHon laws of CaB(ornb.Date PAID •.
O Z NOTICE
Z O NOTICETOAI'PLICttothe after
orlwes king this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__�.FI. Date Recei t#
H shouldou=aeurthwit the ply wi.'Cuch provisions
orthiorsa/the Labor TOTAL-
2
N deemed at
forthwith comply wlttisuch provisions orchis permit shall be .. !BLIILE)ING FE• a^"'j deemed revoketl.a LENDING AGENCY' MIC FEEI herebyafflmnthat there A a construction lending agency for the perform- TOTAL:0 ante^Rhe work for which this permit is Issued(Sec.3097,Civ.C.) TRIC FEE.
L`udera Name - • ` MBING FEE " -
LL F Lendce.Address - QTY: •"� hfECE(ANCAC?PEItvIIT • 1FEE`. HANICAL FEEO W ]akifythatl Wveroadthis appliw[Wnand statethatlheabove in(ormatlonC Is correct.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE PAID:
N relating to building mustruction,and hereby authotlze representatives,of thecity to enter upon theabove-mentloned property for inspection purposes. ALTERORADDTOMECH.(We)agree to sive,indemnify an d keep harmless the City of Cupertino ate Receipt#
against liabilities,j dgments,coasand expenses which may in anyway.otme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL• -
against Cityin conseq a of the gr ming of this permit,
CWL AIRHANDUNG UNIT(OVER 19,000C E) CONSTRUCTION TAX
ignatu eon 8ppEcart/C6ntr,cfor Dat EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)' -
material asdefined bythe Cupertino Municipal Code,Chapter 9.12,and the _ Date Recei #'
Health and Safety Code/.�Seaton 2M32(a)7 +.y HEATING UNIT(OVER 100,000 BTU) TO
❑Yes u No _
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 1 yyj p, �Sn�(IJANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air V' W
U'+a lity Management Disuld? - BOILER-COMP OFT'OR 100,000 BTU) -
I INm g'U 1992
r 1 yea ea rodtheh zar�ousm teriale q ircments under Cbapter 6.95 of . OR.LR-COMP(OVFR 100'000 BTU) /1T
the California Health&Safety Code,Sections 25505,75533 and 25534..1 :" Q
understand that lithe building does not currently have a tenant,that it iimy; NEW RESIDENTIAL MECH.• 5Q.FT
responsibility to notify the occuparfof the requirements which must be met �l'. Ur --•
Prior to issuance of a Certificate of Occopa nn,.
Owner or authorized agent Date -r .,1 ISSUED BY_�J_
s TOTAL:
OFFICE COPY
ADDITIONAL PERMIT-FEES
BUlLDI,NSPWDJECTIDENTIF16ATION VALUAnON
OWNERSNA. -
L�s,� - FEE SUMMARY -
v >Naxc (^
coMENAc oas - _ - .BUILDING �
-PLAN CHECK.'.
�orvTNAc _ 7 -FEE
SEISMIC FEE'
-' QTY. . . ELECTRIC PERMIT FEE v -
OUTLETS:SWITCHES-RECEP. -.ELECTRIC
LIGHTING FIXTURES - PLUMBING
PPLIANCES-RESIDENTIAL .
`f.PANELS- +MECHANICAL.
SIGNS , _t' TOTAL
SIGNS TRANS
SPECIAL CIRCUIT,
_ EMP.METER OR POLE'INS - EENmlr vnuonnox
MOTORS • -_SEE FEE SCH
O _ _' SERVICECHANGE
Z Z
TOTAL
IS ..TE
{'L�j JJ-> - QTY. '; PLUMBING PENMIT .FEE. Oioe EtIECT.ECr., --EEe MeeN..
El
:2 r _ ALTER DRAIN&VENT-WATER IEA 1' i -
-5
BACK BACKFLOW PROTECT:DEVICE -
LL`'UI ORA WS;FLOOR ROOF AREA,COND '
O'w
FIXTURES=PER TRAP {p -;-
(}_`.z
I INC:4
?. GAS-EA.SVSTEM- 0UTLETS _
V GASEA:SYSTE ,OVER 4(EA.)M
INDUSTRIAL
WASTE IN
LAWN SPRINKLERS-IlNC 5 V B - rr
_-_ LAWN SPRINKLERS:OVER 5(EA)
SEWER-SANITARYSTORM EA-200ft/ .+IL -
WATER HEATER W/VENT-.
r WATER SYSTEM
` WATER TREATING EQUIP. (� 1 :_
TOTAL
MECHANICAL PERMIT- FEE
ALTER'OR,ADD TO MECH.
-_ APPLIANCE' - - -
-. -AIR HANDLING UNIT ITO I0,000GF M.) - "
AIR HANDLING UNIT(OVER 10=C F M),
- EXHAUST.HOOD(WITH DUCT) _
- HEATING UNIT(TO.100,000 B.T.U.)
_ HEATING UNIT(OVER 100,000B.T.U.)
VENTILATION FAN ISINGLE) -
BOILER-COMP.(3 H.P.or.100000&T.U.)- _
BOILER-COMP IO:,,1OO.OUD8TU1 SEe FEE SCH:
' '•TOTAL - - -