20137 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project Identification - - 1'IRMITNO.
Building1 2— 3� �_1 y�� - 2 0 1 3 7
V S G Iv{
wnersName: YK one: A
CITY OF CUPERTINO-BUILDING DIVISION -
coatratora .me: _ " LIe.No: OF
/ PERMIT
- BUILDING-ELECTRICADPLUMBINC-MLCHAMCAL CATEGORY CONTROL X aC��gO
Arohitet/Englneee "- j�� - Lic.No. V /
/Y��fS 1)1 •r: BUILDING PERMIT INFO. r,
M pKICvlj i-- —_E.—
QTY ..„ ELECTRIC;PERMIT t ,t,' FEE
Add.:3� KI. I px ^I.LR PFRMITISSUANCE
LICENSED CON RACTOR'S DECLARATION,
IMrebyaf(irmthat lam lkensed underprovislonsa(Chapter9(cvmmenc AI'PfIANCESRESIDF.NI7AL• JOB DESCRII'HON
ingwlth Section 7000)of Division 3 ofthe Best...ad ProfessionsCode,and'my
licenlain ft"
arcs and ef(eRLS
. 3���Q� PANE �UP TO 200ANMS F���
Lkenu Ciam 7 Lees 1
Date Contractor '
ARCHITECT'S DECLARATION 201-1000 AMPS
�Zror
COC I understand my plans shall be used as pubhereds. OVER00
10 AMPS - SQ.IT.FLOOR AREA $/gQ.FT.
U Licensed Professional SIGNS ELEGTRICA7�_•
�< OWNER-BUILDER DECLARATION / T
Ihereby affirm that l am exempt fromthe Contractor's License lawforthe
following reason.(Se tion 7031.5,Business and Profesil...Code:Any city or Eu V
'0$ county which requeresapermetWoomtmetMtegireprove,demolish,orrepair P�..l3s]L_JYwV
anysbutuc prior to itsisauance,ahorequlreathe appllcantfor such permit to )OWER DEVICES 11
ryG file a signed statement that he is licensed pursuant to the provisions of the N - ,
3 0 fn Coamam'.Lice...Law(Chapter 9(commencing with SeNon 7000)of Divi- s Ins Q Af& �,; C
Bion 3 of the Be kness and Profession.Code orthat he b exempt therefrom and VALUATION
g 15, s the basis for the alleged exemption. Any applicant tolacivi of Section 701.5 re any=M- D7ENT1A7LELFJCTR
OZ.S`cod 65 applicant fora peaMted exe the ption. yvioation of
penaltiof not.5 more thanHXTi12F5' V` w
five hundred
nerof thepr. - ELECTR
�n Q I,as owner of the property,or my employ¢s with wages as their solee"O•PT STOW FS TYPE CONSTRUCTION
mmpeasation,will clothe workand thestructure is not Intended or offered forO sale(Sec.7077,Ruslnessand Pro(essims Code:The Contrators License Tawp$$ does not apply to an owner of property who builds or improves thereon,andOCC.CROUP RES UNITSwho d«s such work himself or through his own employees,provided that such _Improvements arc not intended oroffered forsale.Ifhowever,thebuildingorTOTAL: spriofbuimpoeveforpuposle.). -tlurden ofpmving that hedid nabuBd orimprove(or purposeofsale.). G'RERMIT•,' t t -i. FEE Flppp ypNrg Au L as owner of the property,am exclusively contiating with licensedPERMIT ISSUANCE
rontrators to mm W t the projet(Sec 7074 Business and Professlore Code: t'�t
The Contrat.e.License Taw does not apply to an..or of property who ALTER-DRAIN kVEE-WATER(EA)
builds or Impiwremt
es thein,aad who ttras for such plaJms with a
coLRt..(3ator(.)licensed pursuant to the Contrators License Law. :,It �s ; FEESUMMARY
IJ I am exempt under Sec. B A P C for this reason BACKFLOW PROTECT.DEVICE
Date - DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y— N
Owner
1
WORKMAN COMPENSATION DECLARATION RECEIPT X❑ FDCrURE -PER TRSCHOOL TAX Y— N I hereby a(llrm that I have a certlRote of conunt to se141naure,ora AP RECEIPT X
�
certificate ofWorkens Compensation insurance or a certified copythereof(Sec. GAS EA SYSI';1 lINGd OUTLETS PARK FEE Y N
3300,Lab Q
Coman RECEIPT
� Y
Ccrtl(Icd copy is hereby furnished. BUILDING DIVISION PEES
DCenlBed mpyisfiled with the city supeteo�'eL I�ny ,�i D 4 TERc 'roti PLANCHECK PEG
CERTIFICATE OFIIXEM NFROM WORI$ERT3 y'''' (' ^' GREASE TRM PAID
COMPENSATIO,4 NSURANCE IJYp }V_- •� G �, DdIC RCCCI t#
(Tle..edeon need out be eons latedl 9h mM IX To(a h�d�1.$Ityn - �•Ta
($100)or Icss.) P e1�..,.5,. . d _ _ - .
wAia lTEikTirsiwjJ / "TR ENERGY PEE Y N
Icertlly that Nthe performance of th ork forwWeglfils{ierhdt:@"Iiadpy m ..,+,-,
I shall not employ any person In any nner ppgqaa Ip become wbjet to the ,,WA.1.92 SY .ff7�/,
Workers'Compcm.teonlawsof CallfO is.DSte%11. V.^ l-i:aril. -I�i. sS. ?(!. PAID
O Z Applicant p5,.,..NEW RBSIDENTIAL-PLh10: .-�- .Tf. Date ReCel t# �Zs So
Z O NOUCETO APPLICANT:R,after m. gthis CertRlcateofF empif ou
shouldbecome subject to the Worken'tE ematlt I bt eta TOTAL:
41 Code,you must forthwith comply with 71104.tsifil{9k&Vt 6ZrQ� ,
] deemed m=. _ BUILDING p r
W CONSTRUCTION L pQ1y(�'yA�� a�-- SEISMIC PEE a
a. G Iherebya(firmlhat there isammt eoh•@+iN m a• I--_ 1�t10 ELECTRIC FEE (, •C
7 ZO an.of the work for which this permit issued(Sec.3097,Cie.C.) -- — OTAL: a X
LL Landcris Name - Q.I Y. 'r _ ICA' Ill° E PLUMBINGFEE - s
ly enaera Aaarcaa MECHANICAL FEE
O W I certllythatl havercedthisepplicstimand statethatthe above information
(L ismrret.l agree to comply with all ety,and county ordinances and slate laws PERMIT ISSUANCE ��, CC FEES PAID.
} N relating lobtildlng mnstructlon,and herebyauthome,representatives oflhls
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH. Dale ReFlo
e [#
— (We)agree to save,Indemnify an d keep harmless the City of Cu pert Ino
.,.Inst llabilfiies,judgments,rots and expenses wit leh may In any way amme AIRHANDLING UNIT(TO 10,000CFM) S
against sal Ity conse-qu nmol grantingofthes perm it. -
S- ,9 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION
gnatnr Appl ont/Contrador Data D(HAUST HOOD(W/DUCT) CONSTRUCTION
HAZA BODES MATE IA SDI SCIASURE
Will th ppllcant or future building pant Blore o'lvir"chmardous HEATING UMT(TO 100,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Setion 255324)7 HE UMT(OVFR 100,000 BT1n 3
-Q Yea (`]No - LWilltheappllcant ar(uture buildig occupant me equipment or devices VENTILATION FAN(SINGLE RESiD) ISSUAwhicheMa haement air mora Mnantsas defined bythe Bay Area Alr
Quality Maesgement Dlstrit7 BOILER-COMP OHE'OR 100,000 BTfn❑nVes ❑❑No
(have real iM hazallous materials requirements under Chapter 6.95 of BOILER-COMP(OV�i 103,0008TUe California Health 1,SafetyCde,Setions 25505,25533 and 2:537.1.understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECFLSQTT Tur
Pe orisiMlityteoia AlficteofO pancyWrements which must be met V
prior to issuance ofa Certificate of Ocapanry. - &2:
Q� �,'j p�
. f C.!Nffllea
Owner or authorized agent Date �^��y ISSUED BY: _'1_J
'TOTAL:WW
I%
COPY