22071 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
building Project Identification PEIMT NO.
Building Adtlrev1 O SCA�Z+ +L 22 0 7 1
r Name; Tone: GAL p
TE
1=�Q e)R6U,)k) 37 zL't_ CITY OF CUPERTINO-BUILDING DIVISION 2S_rJ
cyowtar.N.me 6 //�I ue.Na: APPLICATION If PERMIT- _6
~'S� y "9 BUILDING-ELECTRICAI.PLUMBING-MTCHAMCAL CATEGORY CONTROE/I t_Q^l
Ar ct/Engin er. Lit.N. 'U` 2
lG Er~s/L _ i:'`"' . "i BUILDING PERMIT INFO
^ I QTY. . . :ELECTRIC'PERMIT• .�': `FEE
Address: Z U /'L (.(/ / J'ps PERMITISSUANCE I -� �.
LICENSE CONTRACTOR S E RATION ,
I hereby afftrm that I sonLtensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
Ing wlthSection 7000)ofDivmion 3 Ofthe Businessand ProtessionsCode,and my
license is in fuE and effect .L PANELS
Lice
Date nse Cl Llek �O C7l v
Contractor AMPS
201-1000 AMPS
ARCHITECTS I L R TON
gipp�++�Z I understand my phru shall be used as public records. - OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.FI.
E Licensed Professional SIGNS ELECTRICAL -
G�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC -
z g I herebyafarm that l am exempt fcmtha Contractor's License Law for the / L 2
po following reason.(Se tlon 7031.5,Business and Professions Code;Any city or "L
O Z a. TEMP.METER OR INST.
�pp countywhlch requlresa perMtto msutmt,altep lmpmve,demolmh,arrepalr
aP ,'ri anystru mpAortoitsi mancgal mquirestheappll«ntf«suchpermitto POWER DEVICES
W9
file a signed statement that he is licensed pursuant to the provisions of the
3u Contractor.Lleeree Law(ChaptI fia11151003).fD
erxe—mngwedonivi-
O�nSWIMMING POOL ELECTRIC
slon3ofthe Busmeaaend Pro(esebneCode)orthat hehexempttherefromand _ VALUATION_
O R the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWIT'CHESHXTIRiES I (� L l „el�
applicant for a permit subjects the applicant to a civil penaltyof not moretlun ` Q b7 V
� G five hundred1,asoowndoler
of he pr. NEW RESIDENTIAL ELECTR SQ.FT, STORIES jTYPENSTRUCTION
I,ss owner of the property,or my employees with wages r there solecoe(Sec.tlon,Buldo the essand rk,andthestructure ode:Ts Contractorot orcense d for
LwaO sale(Sec.7044,Business and Profemloru Code:The Contratots License law _does not apply to an owner of property who builds or improves thereon,and T5
who does such work himself orthrough his own employees,provided that such a y !n1
improvements are not intended oroffered forage.If,however,thebuildingor p U C
improvement issold withinoneyearofcompitlomtheowner-b UderwUI have
fffjuraen of proving that he did not build or improve for purpose of sale) QTY, '';xi'i';]i[�[JMBING hERI>'MIT x `ti.rEEf�','
Lf Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE AT
contractors to constmt the pmject(Sec.7044,Business and Profeselons Code:
E.
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pi fete with e
[y5�fatar(a)u«nae.pursuant to the Contractor's License law. BACK FLOW PROTECT.DEVICE .FEE.SUMMARY
LJ I am exempt under Sec. B k P C for this reason
Owner ate
DRAINS FLOOR ROOF,ARBA,COND. SANITARY Y N
DRECEPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
[]I hereby affirm that I have o ce Insurance
of consent to copy thereof
ora RFLEPT N
3800,Lab o(Workers Comperwtlonlsuurance«acetified copythemo((Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3900,lab C.)
Policy p RECEIPT p
Conway GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cow
ILedifed copy is filedwrmby th the cis. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
edified ropy is flied with the city inspection division.
CERTIFICATE OF IXEMPIION FROM WORKERS' GREASE TRAP PA '''�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT -Mite Recei t Da[
(Thisaetton need nat be completed lithe permit Is foram hundred dollars
($100)or mss.) WATER HEATER W/VENT/E.ECTR E GY FEFy N
I certifyrhat In the performance of the work mrwhich this permit is issued,
I shall not employ any person In any manner an u to became subject to the WATER SYSTEM/TREATING f '
Workers'Compensation Laws of Califomia. Date PAI ays
'I Z z NOTICE TOAPPLICANT:If,oftermaking this Certificate ofExemption,you 'NEWRESIDENTIAL PLMB. SQ.Ff. Date Recei [#(Qptm
F- should become subject to the Workers'Compewatlon provisions of the Labor TOTAL: y.
CC W Code,you moat forthwith comply with such provisions orthis permit shall be BUILDING EEE
LU > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafRrmthat there is a rnvtmtlon lending agency forthe perform- ELECTRIC FEE
Z arm of the work for c thee permite esued(Sec.3097,CIv.C.I TOiAI'
V O Lender.Name Nam' 4 PLUMBING FEE
U. F Lander',Address QTY.. MECHANICAL �OMIT FEE, MECHANICAL FEE -
OW I certifythatl have readthis appB«tion•nd Rale that the above Information
S Is correct.[agree to complywlth all cityand county ordinances and state laws PERMff ISSUANCE FEES PAID,_
/
} W relating to building construction,and hereby authorize representatives Of this - b2
[_ Z city to enter upon the above-mentioned property f«inspection purposes. - ALTERORADDTOMECH. Date - ReCel [#
z (We)agree to save,indemnify an d keep harmieas the City of Cupertino - P
against llabililles,judgments,costa and expenseawhich may in anyway accrue AIR HANDLING UNIT DO 10,000 CFM) W SUBTOTAL:
a npl�d City In m9�7uence o(the granting of this perm . - -
.,/yt�/ AIRHANDL[NG UNR(OVERIO,000CFM) CONSTRUCTION TAX Zgls
Signature
seooff Applicant/ContractorYf /to EXHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oaupant store or handle haaardous HEATING UNIT(TO 100,000 BI" Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z'and the
health and Safety Cade Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
QYes 0
Wilitheapplicanto mmbuildingocmpantuseequipmentordevices VENTILATION PAN(S RESID) ISSUANCE.DATE
-
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dist t7 BOILER-CAMP O}I'OR 100,000 BTU)
RRave009-Na-NaW1�
ave read the I, materials mqufrements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) '
the California Health k So fety Code,Sort ions 25505,25533 and 25534.1 JUN
7'1� VS? 'J(]��
underds nd that if the hu tiding does not currently have a tenant,that it is my NEW RESI DENTTAL MECH. MMI�
SQ.FT, 1a7
nspons�b Ityto notify the occupant of the requirements which at be met
Piaeorto Lss race of a Ccftjgpm of Occupancy. -
City 0111U.-Peruen
Own erorauth.d.dagent _ ate TOTAL: 1 165UEDBNA 3
' a
OFFICE COPY