22597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BuildingPro'e denlificatlon r PERMITNO. >- '
Building Address: L.v'r'
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su �3l one:
A
CITY OP CUPERTINO-BUILDING DIVISION � J
c ctar's Na Lic.Na: APPLICATION / PERMIT L l__q L
MW
1-9
�AS-F a s t-z � Y BUILDING-ELECTRICALPLIMBING.MECHANICAL CATEGORY CONTROL x
ill neec Llc.No%fj ,
QTYELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.Z QA?o L£ V „�— PERhBTI55UANCE I"'2s('� I�/I 11A
LICENSED CONTRACTOR'S DECLARATION
L�
I hereby affirmthat l am licensed under provisions of Chapter 9(commenc APPLIANCESRE9DENIAL JOB DFSCRIP170N
ingwith Section 7000)of Division 3 ofthe Busieessand ProfesslonsCode,and my
Ii cense la in f III and effect. PANELS
License Cl _
Lie. t,6 2 C I=—p�L
Date ��--Contractor 2011000 AMPS v
(IArushaH etu CLAR 1 -OVERIODOAMPS FT.FLOOR AREA
q�+0� I understand my phre sha8 W used a public records c''Q
i. Licensed Professional SIGNS ELECTRICAL
<�$N OWNER-BUILDER DECLARATION I S LCIRCI'71T/ I '
F, Z IherebyaffirmthatI am exempt form the Contractor's License lawforthe ..S O 10 9�
OO,'-c following reaver.(Section7031S,Businessand Professions Code:Anytlty or l 1. C) CJ
Zt u9 P.METER ORPOLE7N51 I a
cauntywhich requim a penrdt tommtmd,alter,improve,de=ILbh,orrepair
�`< anystructureprimtoitsissuance,alsorequirestheappliantforsuhpemdtto DEVCF��� I
�.0 Ole a signed statement that he b licensed pursuant to the provbt of the
29µ Caotacmra License Law(Chaptsr9(mmmenringwlthSect1on7000)ofDivl-
S ,Ion3ofthe Busnessand Pmfe iamCode)orthathebexempttherefromand LE"E VALUATION
0 the basis for the alleged exemption. Any violation of Section 70315 by any ETSSWI /
applicant fora permit eubjeda the applicant to a civil penalty M eat more than 36.44'2
^ c five hundred dollars($500). NEW RESIDENRAL ELFLTR Pf. 111
f,as owner of the e� STORIES TYPECONSTRUCTION
property,or my employee with wages as their sole s,t O
rompecc.17 n,wBldessand Pr andthestCode:The Conttendedo License
eLaw "L
�O dosale not apply
to an owner
df property
Co b:TM1s or improves
License Law
does not apply to an owner ofprop¢rty who Wilds orimprovethereon,and OCC.GROUP RFS.UNITS
whodoessuchworkhimself orthrough hisownemployees,provided thatsuch
improvements are not intended oroffered forsale.I[hmvever,thebuilding or TOTAL. 4 4 If
Improvement bandit withinoneyearofcomp:diorytheowner-bullderwill have
thWrdenofproving that he did not build orimpowe for purpose ufaele.j. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
rj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '
contractors to construct the project(Sec.7044,Business and Nofesslons Code:
The Contactor,License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojects with a AL
con,Il[(elor(a)license pursuanttothe C.m.dora License Law. FEE SUMMARY
IJ I am exempt under Sec. B&P C for this reason BACK T. OUTSIDE FEES
SANITARY Y_ N—
Owner Date DRAIN M,T %'-t RECEIPT'N
WORKMAN COMPENSATION DECLARATION �n `/'l Fa
• ❑I hereby affirm that I have a certificate of consent to self-Insure,or a FO(ll)RES iG" (^ 1t, 900E TA% Y_ N
nlfiateofWorkesi Compensation Insurance ora certified copythercof(Sse. _.T' RECEIPTN
3800,Lab C.1 GAS EA.SYSTEM-I INCA 01 .,'.� Y— N-
1 A
Pollryp a���-yk973 `�11 d. .�_:.LILDINDIVISIONF[[S
Co nv—— _ p GAS EA.SYSfEd-OVER"
MCcolfied copy 5 hereby furnished. - r
❑Certified copy is filed with the city Inspection division. GREASE/WDUSTAL WASTE INTERCEPTOR ILANGHEGIC FEE
CERTIFICATE OF IXEM PFION FROMWORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM T.A.200FT. Dale Reeel III
(This section need na be completed lithe permit b for one hundred dollars
(SI00)orless.) WATER HFAnAW/VENT/ELFCTR ENERGY FEE Y_ N fi
I certify that in the performance ofthe work forwhich this permit b Issued, /x
I shall not employ any personWATER SYSTEM/TREATING In any manner so as to become subject to the P 9, ,
l Workers'Compensation Laws of California. AID
la.Date
O Z Applicant NEW RESIDENTIAL PLMB. SQF. Date Recei # 1S.00
Z O NOIICETO APPLICANT:If,after making this Certificate of Exemption,you L
should become subject Workers'
to the Compensation provisions ofthe Labor fl / TOTAL
lip Code,you most forthwith comply with such provisions or this permit shall be t BUGFE s
CX-
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE s
a Z I hereby affirm that is a construatmn lending agency forthep ore, TOTAb ELECTRIC FEE t�
V — ancuoftheworkf v I<h thbp 4wcdW Clv.^J 4-
0
Tender's Na O __ PLUMBING FEE L't
I— Lenderaaddns9 —3�eur QTY. MECHANICAL PERMIT FEE
li — e -on MECHANICAL FEE
O W emit. tagree vcom y with allcityandcumand snte that cesand gate)bove sus
ucoingto agree to complywo,andtyandcauntyordinanmandgatelaws PERMITISSUANCE /�('XJ FEES PAID:
} N city tngn Wildingromeve-metioned rebyamhorinrectionpurposofthis
FZ cityto
to the above-mentioned property for Inspection purposes. ALTER ORADDTO MICH. Date Rees tq
(We)agree m save,Indemnity and keep harmless the City of Cupertino
V
against liabilities,Judgments,costs and expenses whlchmay lnanywayace a AIR I-IANDLINC[A7T(fit 10,000 CFM) SUBTO AL:
zgal ityin consequ of the granting M this permit
AIRHANDUNG UNIT IO,WOCIM) CONSTRUCTION TAX 2q,
Sigsusureof Appllcam/Contractor 1D.te f EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX AID:
HAM R DOLS MATERIALS DI SOLOS URE
Wnitheapplicant or future building occupant store or handle hazardocs HEATING UNIT(TO 100,0D)BTU) Date Recel IM _
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Iiealthand Safety C ctlon 25532(a)7 HEATING UNIT(OVER IW,000 BTU) TOTAL.) at
F-1Yea
IN.N.
Will theapplicant orfutu Wilding occupant use equipment or devices VFNIILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havardoua al: ntaminants as defined by the Bay Area Air
Quality Managerrcnt oua BOILER-COMP OHP OR 100,OM BTU) P A i D
4 Yes
have read the hazar ,rmtedab requirements under Chapter 6.95 of BDILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 2550.5,25533 and MTM.I - NOV {j�
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MSCI 1.' SQ.FT Itl V 190J
responsibility to notify the occupant of the requirements which st be t /s v
prior ce Of a CertIfic fOmparry. /, l Lt 0 CII YUI_ cupt:
Own rauthoriu agent C Date TOTAL: ISSUEDBY:y(�h�.ava+
OFFICE COPY
�- ADDITIONALPER= FEES -
BUILDING PROJECT I DENTIFICATION' VALUATION -
ADCRETE
OWNIRS _
NAME ',p FEE SUMMARY
PHONE 2-& ?oz - /' !V
COONTRACTOR5 / "BUILDING A
)4o,,I/ l rvo. } ZC,V 2-
CONTRACTOR
- PLAN CHECK-..
CONTRACTORS FEE
OOREss
/hz3aStrncc ' PHONE' ISG 77 Z-2 SEISMIC FEE , f
i OTY. ELECTRIC PERMIT FEE . . -
.,. UTLETS-SWITCHES-RECEP. ELECTRIC _
LIGHTING FIXTURES - :'PLUMBING
APPLIANCES-RESIDENTIAL '
-PANELS _ '-MECHANICAL
SIGNS.. _
SIGNS TRANS. - TOTAL'`-
SPECIAL CIRCUIT
PIRmrt VALIDATIONVALIDATIONEMP.METER OR POLE INS.
MOTORS'- SEE FEE SCH. -
-O" SERVICE CHANGE
z:z -"
F O TOTAL
'cr T ^' - ISSUANCE DATE`
LU _ CITY. PLUMBINGPERMIT FEE BLDG.- ELECT. PLO. NIECH.
CL 0
-��
Z% ALTER DRAIN&VENT-WATER(EA.)
. O BACK FLOW'PROTECT.,DEVICE
O w DRAINS-FLOOR,ROOF,-AREA,COND. .
} y FIXTURES-PER TRAP ( .:
Z GAS=EA.SYSTEM�IINC.4OUTLETS
' 7"75
O . GAS-EA.SYSTEM.--0VEfl 4'(EA)' (
.:INDUSTRIAL WASTE,INTER.
_ LAWN SPRINKLERS-I INC5 V.B.
LAWN SPRINKLERS-OVER 5IEA.) '
SEWER-SANITARY-STORM EA.-2001t/ _
WATER HEATERIW/VENT - -
WATER SYSTEM _
WATER TREATING EQUIP, -
GTY. M ECHANI CAL PERMIT - JF�E
ALTER.OR'ADD TOMECH.,. - - - -
APPLIANCE,
' AIR HANDLING UNIT(TO 10=C.F.K) ';
AIR HANDLING UNIT(OVER 10=C F.M.)'
EXHAUST HOOD IWITH DUCT)-
- O
HEATING UNITATO 10 18920LHEATING UNIT(OVER 100,000BU.) �r:I•bf '
VENTILATION FAN (SINGLE)' Llt 11jEV-
BOILER-CONPQ H.P.Or 100,000B.T.U.)
BOILER-COMP Iowa loo.000 BTU)SEE FEE SCM. '
- TOTAL