20279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Projert Identification PERNRTNO.
Building Addu� 20279
ra300 r&tE)jAw
ams: c one:
J ¢ CITY OF CUPERTINO-BUILDING DIVISION
Contratim.Nam:� 4Ze),,� N. APPLICATION I PERMIT ��
�t/ ' ��' Gv /•7// BUMNGELKMCALI'LLT. BINGMFLHAMCAL CATEGORY� CONTROL/'l0* ArdRect/Fagineer. 1X.
2S
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRN[ITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I herebyaffirm eutlam Rcen.eduMerpro Worsof Chapter9(omunrc APPLIANCMIf9DEMlAL N
hngwlthScNon7000)of Dlvi.bn3dtbe8usines dl'mfrel 'Cade,and PANELS
I pea.bin full fpQa,and effect. 2.'
Liar.Claro'eOK_ —
Date Coritrictor
ARCHITECT O 00ALMN
07C ]uMerslard my pbrshall be used as publlcrcmda OVEROVER 1000 AMPS 9Q.F7.FLOOR AREA $/9Q.FT.
U
Licensed Prdesbrcl 9 S E[FL7RICA
OWNER-BUILDER DECLARATION
SfAd!ALCIR
iP, ? Iherebyaffi.that I.exempt from the Contractor's Lice.Lw for the
ZO F- following nasty.�ectlon 70)]5.Buainm and Prufesebra Code My cityor TENT �..
0z county which requbena mr
permit toutr4 ualter,Improve,derrulbh,orrepalr
anystuctusprbrtolslw a,abonqubntheappbcantforuchpemdtto
6' Ne a signed statement that he It Licensed pursuant to the provbbru of the
� 3coF. Contractor.Lkerue Law(Chapher9(commencing with Section 7000)of Divi- NG ELE
OJ don3 ofthe flushness and Prdembv Code)ortha he b exempt thenfromani VALUATION
19 the basis for the alleged exemption. Any violation of Section 7m15 by any OUTIXT&SWTPCHES-FDfIiIRf 3 �� RlA'Ot
O applicant fora pemdt subjectstheapplleamtoacivll penalty afnrs mumthan ].seal
Ove hundred dollar.($500).
�� �1,u awrcr o/the Property,or my empbyen w0h wages as their tyle NEW RESIDENTIAL EI.ECTR 9oF1'. STORIES TYPE CONSTRUCTION
compcvatlon,wW dothe work,and theatucture is not Intended or offered for
psale(SL,70G,Buahrussard Pmfeslom Code:Tlse Cmdnctor,Uor.Lw
313 don text apply to an owner of property who build,or Improves thtmur,and OCC.CROUP R6.UMI5
E who dea.uch work hhmeseltmthwr,gh his own employeprovided that such
improverrcns sn wt Intended oroffered for Bale.If,however,thebulldNg r TOTAL
improvmentbnoldwhMn he did otbuil porimpoveforpurpoeerwWluve
tta-¢rrason,of the toert riotb..htshnprovefacting seotnkJ. QTY. PLUMBING PERMIT FEE
Ltr ec an owner mthe property,am ev0K Busy e%% noting with ns Codd FLOOD ZONE APN'
mntracta.to mmluctthe Project(See 7004,Bualnem and l'desbm Code: PERMIT ISSUANCE
The Contractor.License Lw dor not apply to an owner of property who ALTER-DRAIN La VENT-WATER(FA)
W Bol, or toy.thenen,and who coninCs for arch pko)ecte with a
owu'+c<orts)licensed pumrant to the Contractor'.License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
U seder Sm am exempt sSec B Q P C for this noonQ�Sl DE FEES
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
-• WORKMAN COMPENSATION DECLARATION
711RECEIPT s
1 hereby aiftmo that I have a oerROate of consent to.If-Won,or FI)CTURE,STRAP SCHOOLTAX Y N
certlflate odWor],ensComperesuattort lmurarmora artBkd copy thered(Sec. RECEIPT
3800,Lb C.) /1 GAS EA.SYSTEM-1 INCA OUTLETS PARKFFS Y N_
Poiky/ Z�q V RECm'I'.
my ,�/ GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
er MM.pybhertby(urtJ GREASE/INDUSTRLWASTEINTERCEPIOR' PLANCFIECK FEE
rfileampylaherewlththshlid. pectbn alvWm. "`�
CERTIFICATEOFID(MvI IONFROMWORKERS GREASE TRAP PAID { -q
COMPENSATIOCI INSURANCE SEWER.SANITARY-STORM EA 200FT Date Recti t# ,
(Thissection need net becompleted B the pemJt Is lorow hundred dollars
(SI0(fiorleo') WATER HEATERW/VIM/EISCIR ENERGY FEE Y N
¢Ny hatWNepe omunora(hewo kforwh htwp rt kb ssued,
I sha0 not employ any person b any manner so as to become subject to the wArm SYSf1M/TREAT iNG
walker;Ccmpen..tbn Laws of CeEfcrnln.Date PAIDMT
O = Applicant NEW RESIDEAL PLMB. SQFT. Date Recet t#
Z O NOTLCETOAPPLI .1f,aftermakingthb CeNifnteof Exemptbmyw
N should been.subject to the Workeri mr
Copeatbn provisions of the Labor TOTAL: I
CC _ Code,you must fort hwhh comply with such provbbrs or this permit shall be 7
W > deeencei re.9tea. BUILDING FEE
CONSTRUCTION UCON LENDING AGENCY SEISMIC[1 I he.by sfflrm slut then b a mrslruction kMing agerrq for the performs ELECTRIC FEE
Oance ofthework forwwh this permit b isued(See.3097,Civ.C) TOTAL.
LL LMcr,Add. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LL U InrUfyth,nlhave radlwspp0adonard ass firths above inforrrutisn MECHANICAL FEE
O W bcomeef.l agreetu comply with all city and nountyordhnanawand,tatelaw. PERMIT ISSUANCE FEES PAIL ..
}.a relating to building construction,and hereby authorb,repnnentativeit of this
U) by to entero nthe above-mrntbrcd for W ion ALTER OR ADD TO MECH.
F- (We)agree o uve,Ineemnlry an d keep ha mles the ity o/Cupertino Date Recei t#
V against Bab ,ju dgrrcrm,co,bard rpense,which mayb any wayamue AIR HANDIJNG UNIT(I7O 10,000 CFM) SUBTOTAL:
ag.i Cly in comeelueneoft gnMing of this permit.
AIR HANDLING uNrr(OVER la,aaocFaf) CONSTRUCTION TAX
�L 7v tiV� CONSTRUCTION TAX PAID:
Sig dAppOo,ZARDOUSh Date EXHAUST 110013 M'/DUCE)
HAlARDOUS MATERIALS DISCLOSURE
Ithe applicant or future building occupant mart or hnMkhavrdous HEATING UNIT(N 100,000 B11n Date Rttel [#
matcrbl as dc0 ned by the Cu pertlno Municipal Cade,Chaptcr 9.12,and the
IWIth.nd Safety Codcr.�SWi.25532WTU)T ]EATING UNIT 10D,000 BTOTAL:
r-1Y. u No
Wllltheappliant orfuture building occupant use equipment ordeviav VENTILATION FAN(SINGLE RUgD)
`
ISSUANCE D
a
A
TE
which eMtluvrabna sdArcd by Bay Area Ab
aIBy Mageent Drict? BOILER-COMP OBEOR 100,0(U BTO
Y RSV
hove read the Fav❑aNerlab requirement,;under CLpnr6.5 of BOILFRQOMP(OVQ1W,OW Sl1)
theGlf= lleAh&SafelyCodaSiom25505,25533ad2S534.
1 t.)
understand that ifthe WOdingdoesnat currentlyhaveatenant,thal Loamy NEW RESIDENTIALME(H. SOFT JUL
responsibility to notify the occupant of the requberrcnts which rruta be red
prig to I,uarer d a Certificate dOceupancy. as,ss,ath�tm
Ower, .I,thorbadagent Date ISSUEDBY:
TOTAL:
OFFICE COPY