21901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification _ PIRM TN9. 19 D 1
BuCiing Ad ress:
11124 LA P6 )v1.4 QP'•
wnero ams: {f77 II one: p A
U 1�A�r,) L, l7UlJIb 2S5—U¢R3 CITY OF CUPERTINO-BUILDING DIVISION
Contndors Nemo: uc.N°: APPLICATION./ PERMIT
Architect/Engler. Llc.Na BIALDINCELECTRICALPLUMBING-MECHAMCAL CATEGORY CO OLa
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO`,:
Add.. �v ❑ El ❑
PERhITISSUANCE IW/`h
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l sent licensed under provisions of Chapter 9(commenc APP1IANCES-RERDENTIAL JOB DESCRIPTION
ingwith Section 7000).f Division3ofthe Busine.and ProfesslonsCode,and my
limew Is In full force and effect. PANELS a�Cr'7�` l ♦(�t I
License Chiss Lk.p �6-w�L VJt•T~''�
Date Contractor —UP IQ 2DQAM1!S
ARCHITECTS DECLARATION 201-IODDAMPS
Pggq+rA zz I understand my pia.ahaB be used.public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00
m d of Licenred Professional SIGNS ELECTRICAL
z
<Qm OWNER-BUILDER DECLARATION
`to SPECIALCIRCUIT/MIST '
f., owing Rafifiren son.(hatlam31.5,B from the Contractor's L Code:ense ny for the '
r4FQ !o0°wingreasequi apeion? ttom Business and Pmlessw e=ltshnydtyor RI'OL -[nisi. -
,�W countywhimp6orlmape ancoawrequimatheaplivntf wh,°rrepao
,,��C1i anya signere tatements that
he b;Homsed rersuant to the roviko permit e POWP -
0 fileCo a signed statement that he is Bcenad pursuant to the pro 7000) of the
Contnctors Lice.sLow(Chapler9(mmmencingwithSectWn7000)ofDivl-
Q3 1'n SWIMhIING POOL ELECTRIC
O slon3of the Business and Professio.Cde)orthat he Vexem therc(romand VALUATION
< the basis for the alleged exemption. Any violation of Section 70315 by any Is�,s
CCC applicant fora permitsubje=istheappilcentmadvil penaltyof not monthim �-El u �
o.5 Ove hundred dollars($500). NEW RESIDENTIAL ELECTA
I,as owner of the roPetit,or m employees with wages SQ-Fr' STORIES TYPE CONSTRUCTION
t-'Z F1 1, Y emP°Y Be
s as their sole
�Za rompc.atl.n,wllldothe work and the structure isnot lntendedor offered for
5�D site(Sec.7lM4,Busln ss and Professlow Cde:TM1e Contraaofs License law
$$ does not apply to an owner of property who Wilds or improve therein,and OCGGROUP RFS.UNITS
who does such work himself orthraugh hisownemployees,provided that such
improvements are not intended oroffered for sale.If,however the building or TOTAL:
improvement issold Mthinoneyearofcompldbmtheowner-W ilderwiil have
e�rde.of proving that hedidnot build orimprove for purpox ofsaleJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner o!the property,am exclusively contrading with Ilcensed
.in. orsbe construct the project(Sec.TOM,Business and Professlo.Cde: PERMIT ISSUANCE
Contactor'.Licence law does na apply t°an owner ni property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such da p4ojewith a FEE SUMMARY
contractor(s)licensed pursuant to the CoMnum,O'.Lt...Law. - BAIX FIAWPROTHCT.DEVICE '
❑T am exempt under Sec B& P C for this reason
OUTSI OF III,
DRAINS FTAOR ROOF,AREA,COND. SANITARY Y N_
. Owner Date RI:GEI'C p
WORKMAN COMPENSATION DECLARATION FLX�S PER TRAP SCHOOL TAX Y N
r-11 hereby alfirm that I have a certlOcate of consent to self-Insure,ora RECEIPT 0
certificate otWurlams Compensation Laurance ora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
MOKLLab C.) RECEIPT p
Pollcyp nGAS FA.SYSTEM-0VER4(FA)
Com BUILDING DIVISION FEES
�Cc y TCied copy is hereby fumikied GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMITION FROM WORKERS' GR HTRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FF. Date Reml t#
(This aedion need not be completed B the permit is for one hundred dollar
($10))or less) WATER HFAtER W/VFM/FI.ECTR ENERGY FEE Y_ N
I mrtify that in the perfomance of the work f.rwhlch this permit la Lasud,
1 shall not employ any pecan.In any noon,.as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O
NOTICE APPLICANT.If,after making this Certificate of Exemption,you
Hshould become subject to the W.,ken'Compe.atton provuio.o(lhe Labor TOTAL:.
N Code,you must forthwith comply with such provisions or this permit shall b, BUILDING FEE
W ] dmmed revok RL
CONSTRUCTION LENDING AGENCY SEISMIC FEE U
Il Ihereby affirm that there is a construction lend ing agency for the perform TOTAL: ELECTRIC FEE
is
7 Z arm of the work for which this permit issued(Sm.3097,Civ.CJ
U O meds.Name PLUMBING FEE
LL H Lender'.Add... QTY. MECHANICAL PERMIT ' FEE. MECHANICAL FEE
OW I certilythat l have read thisapplication and statethatthe above information
a ucorrect.I agree to comply with all cityand muntyoMinanm and statelaws PERMIT ISSUANCE ' FEES PAID:
relating to building construction,and hereby authorlu representative of this
N city to enter upon the above-mentioned property for Inspection purpose. ALTFRORADDTOMWH.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,pdgments,mks and expenses which may in any wayacerue AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
ag 'nst sai City in conseque ceof the granti g fth permit.
_g_q MR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION TAX
Signature of Applicant ontractor Date E)(HAIJs'THOOD( ,/DUCT) CONSTRUCTION TAX PAID:
HA2lA R DOUS MATERIALS DISCLOSURE
Will the applicant or futurcbulldingo=pantstore or handle havrd.us F[EATINGUMT(T010),000BIU) Date Recei t#
material as deOnd by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cde Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea t]No
Willlhe applicant or futurebuilding occupantvse equipment ordevices VENTILATION FAN(5INGLE RESID) ISSUANCE DATE
which emit hazardous air contaMwnb as defined by the Bay Area Air
-� Quality Management lk.ttict? BOILER-COMP OFIPOR 100,00)BTU)
4Yes ❑❑Nom
haveroad the hazardo terialsreqummentsunder Chapter6.95of BOILER{OMP(OVEIt100,000BTU)
the Califomu Health&Safety Cde,Serio.25505,25533 and 25534. I
understand that if the building doe not currently have a tenant,that it is;my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the repimmenta which must be met I �9g1
prior to issuance of a Certificateof Occupancy. III KIK
Owner or aulh.rimd agent Date IOTA L: ISSUEd"AR9
'
OFFICE COPY