20135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT W.
Building Address: - f")O a�
j G I3
MorDTTre:rcr• a,n 2b$'!;L'377 CITY OF CUPERTINO-BUILDING DIVISION /
Contractd, me r Gc.Na APPLICATION / PERMIT 4
CATEGORY CO
BUILDINGdF>rTRICA4I'LUMBINGh1FiCHANiCAL CA 'V
� AmhBea r: Lie No:
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
AddreslI I'FRMI'1'ISSUANCQ ❑ ❑ 1:1LICENSE CO A OR5 DECLARA ON
[hereby affirm that l am Licensed under prorWoeu of CM1apter9(csmmrn APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing Mth Seabn7000)of DMe.3ofthe B.,i,.and ProfndorsCode,and my
license is In full form and effect. /l. �ID PANELS
License Cha Lic.l' X11
DateCOntnctor (r L
ARCHITECT E LIBATION 2I1-1000AMPS
x IunderwrdmyphroeluRbeused npublerecards. OVERIOOOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
j Licero d Prdesebru SIGNSEL.ECIRICAL 1
OWNER-BUILDER DECLARATLON SPCCULCIRCUIT/MISC h/
Z IhertbyafOrmt tlamnemptfrmnthe Contmcior'',L{ nm L,wfmthe _
0� following rtaamm.&cfion7mlS,Businesand PmfealorsCode:Any city or TMRMETERORPOLE
cauntywhkhnoqubesapemdttommtmMAter,i prn,d.Uh,ormpalr
anyetructurt price to lNlauar�ce,,laonqulnv theapp0ont foreuch perMtto POWER DEVICES
Ufile•signed statement that he Is Bamsed pursuant to the pmvbims of the
Contractor's License,Law(Clupter9(commencing with Section 7000)of Dlvl- SWIMMING IPOLa4wA M�03 dan3ofthe Bualamsend Ptdmbm Cmrd tA VALUATION
ode)orthdhebesptthemfmma
y-' the Wale for the alleged nemptbn. Any videlon of Section 76115 by any r�
0 applicant for.permBsubjech theapplicant to•civil penaltydrot more than OVILETS C<D
BTwndred ddlart MM. NEW
U I,a,owner of the property,or my employewith wages their wet �'�
rs u STORIES 'TYPE CONSTRICTION
C compen,ation,wlldo the work and the stmdb rot t intended or offered for
5 O sale(Sec 70K Business and Itdmbro Code:The Contractor,License law rj
S don vat apply to an mrs r of property who builds or improves thereon,and OCC.GROUP RES.UNTIS
whodmsuchwork hlvself mthnough hl,ownemployees,provdel that such
improvements am not Intended oroffered for sale.IL however,thebuilding or TOTAL
Mpmvemed b said within meyeuofcompletlon,the ownerwllderwill have
t rden of proving the he did rax wild or Improve for po,s urpof,ale.). QTY. PLUMBING P MI FEE FLOOD ZONE APN
U L a,owner of the pmpedy,am euhsively mntnnbg with licensed PERMIT ISSUANCEcortran d ee ctoto cerstruthe project(S70K Buslnm and Profmbn Code:
The Contractor's Lken,e Law does not apply to an owner of property who
builds or Improvthereon, and who commis fm such Plojem whh • ALTER-0RAiNkVFM-WA
e
FEE SUMMARY
ry0{(acamc,tsntunder ant to McCmtnctor',Llcerise Law. BACK FLOW PROTECT.DEVICE
LJ I am aempt under Se B k P C for tMs noon
DRAINS FLOOR,ROOF,AREA,GOND. SANEEARY Y_ N_
• OwnerDee RECEIPT Y
WORKMAN COMPEcSA NDECLARATION Fp(TUppg l'ER TRA[' SCHOOL TAX Y_ N_
❑I hereby affirm the I have o certificate of consent to,elf-loon,m
RFOFRrE,
390,ab ofWorkere Compewtlmin,unnmmacedlfled mpytFenof�ec. GAS F.I.SYSLEM-1 WCl OUTLETS PARK FEE Y N
]800,Lb CJ ftQ'E71'f A
Pdky l��r�.� GAS PA.SYSTEM.-OVER 4(EA)
Co any A./ r BUILDING DIVISION FEES
I ICenln py b hemly filed
thehN. CREASE/wIwSIR1.WASTE INTERCEPTOR PLANCHECKFr
Cmlfled copy I*Ned with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID 1 d
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA pQ,T RPC i t11 MAO
(Thia,ectbn need not W completed Lithe permitb for one hundred dollars
(fl 00)mlmJ WATER HEATER W/VENT/ELECTR ENERC L N
I certify that to the petfomunm of the work forwhlch this Permit b hailed, `
1 shall not employ any person In any manner n as to become subject to the WATER SYS IN/TREATING
Wmkeri Compensation lawed GBfomla.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Re i aK�
Z O NOTICE TO APPLICANT:If,after mating this Certificate of Pa nrptlm,you
CC N ,M1mld become subFtt totM Workers'Compenatlon pmvlabm aftM1e Labor TOT
Code,yw mrd forthwith comply with such provisions or this permit shell be BUILDING FEE
deemed revoked.
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihucbyafflrm(lot them is a construction lending agency for the perform ELECTRIC FEE Z sena of the work(or whkM1 this peered bbmred(Sec.3097,C1v.CJ TOTAL:
Q0 1,e der,Name PLUMBING FEE'
LL H Lender's Aaama QTr. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mdlfythel havereadthbappBotbnand stamthethe above lnformatlm
is roM
C correct.l agneetocomplywhha8 etyard countyordhananand etatelaws PERMIT ISSUANCE. FEES PAID:
>. relating towilding construction,and hereby authodm representation ofthb
F = citytoe.mrupon the abase-rrcntbned property for inspection purposes. ALTTRORADDTOMECH. Date Recd [N
(We)agree to ave,bdemdly an d keep harma lethe City d Cupertino P
V egabut WbWties,Pdgmends,meaand eaperun which may i.eywayamue AIR HANDLING UNIT(r010,00)CFM) SUBTOTAL:
agalrot d hyU consequeno:oflhegnMingdthlspemW.
9� AIR HnIVDur:GUNrzroVERl6,000ctTd) CONSTRUCTION TAX
g turn of Appbont/Cont Da- to - IXFUUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCttOSU}}}tttE
I Will the applicant or future buiding occupant smrtor handle hanrdoua HEATING UNIT(TO 100,0(6) Date Re ei tN
material a,defined by the Cupertino Municipal Code,Chapter 9.17,and the
I Ialth sed Safety Code Section 2S5324)? HEATING UNIT(OVER 10,000 BE TOTAL:
❑Y. M No
Will the applicant or forum wilding occupant..equipment or devirn VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit W nrdous air cementoem as defirud by the Bay Area AU
Quality Management Dbtrkt7 BOBRR{OMP OI-D'DR l00,IX9 BTU) r�D
Yn ❑No
Ihave read the harsrd usmamriabr q fimmnbund,,CWpter6.95of BOILER-OOMP(OVER 100,000STU) V 0 ��Jp�
the Gumla
BfHeahhkSaf CW,S,diom2ri565,2W3and25M. 1
understand that lfthebu0dingd not currently have atenanL that It Is my NEWRESIDENTIALMECH. SOFT
r poruNinytondilytheoav 't dthe requirements which carves be met '
rbr to beuance of a Certificate o Occupancy. l��Aa asF/s,usesliww
— `Z jai sTu1+�1i11IM� t
mauthorl age tISSUED BY:
' TOTAL:
OFFICE COPY