23234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
13.11,11.5 project Idendfkatlm PERMITNO.
Building Address: n a"I f"I N� A
ULPr lA4Jc 23234
Ownersame. one:
j NIGuc HI CITY OF CUPERTINO-BUILDING DIVISION
Cmtraaora N. Lk�.+No: APPLICATION / PERMIT `(
l H LVh I` I I BUILDMGELBCTMCA4I'LIMBING-MECHANICAL CATEGORY CONTROL N
P_ Architect/Esglneer. Lk.Na
Q ELECCRICPERMIT FEE BUILDING PERMITINFO
Address _ PERMITISSIIANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Iherlmthatl n3of under pravW« a( uphr9ac APPLIANCESRESfDENffAL JOB DECR�1lON
Ing with
Socl1bn9(OD)of DiAsion3oftieguJ�sand Pm(evlmaCode,and
my '
License b in fu1j(o�e1and elect PANELS r Qs
Licence Ct.. .Lglk.# je�o.3Si� Ip
Date Contractor UP TO 2DO
ARCHITECTS DECLARATION1201-1000 AMPS
QZ I urderwnd my plans shall be used a public record& OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
X([j Limrard professional SIGNSELECTRICAL �j (� LED ' A'
Sr� OWNER-BUILDER DECLARATION SPLCIALCIRCLIIT M6L A`f `—ice ,v
Ph,pa IhertbyaHirmtlatl.mexemptframtheCordnaor'aLkunselawforthe --COMP/UTE R
following nib req(Scalar 70515,Brimsct ami r impowe,Code:Any sty or //
K � muntywhkh requlroapermdtomrotma,alter,improve,demoWh,or reply hMP'MLTER OAI'OLE INST, o^y'
q'4 ad m
nystiusure prbrm Its Issuance,also requires the appllantfor such permit to POWER DEVIL DATE
L-° S Ole a signed the he b M Ilaenspursuant to the previsions of the
is Cnntraaor's License law00uspter 9(comrpnang with Seaton 700()of DIW-
�0 If
slon3 of the Business and professions Code)or that he 6 exempt therefrom and SlVA1MING TOOL ELECTRIC VALUATION
6 the basis for the alleged eaemptim. Any violation of Section 70115 by any OVIi.ETSSWLTC}DSFUCIIIR6
applicant fora permit subjects the applicant to a diol penalty d not more than
a fW hundred dalistai WOO.. NEW RESIDENTIAL ELECTA SQFC.
�I,as owner of the Property,or rtry employees with wages as theb sob SIORfE9 TYPE CONSTRUCTION
76 eompe—don,will do the work,and the strusure 6 not Wended or oHerodfor
O sab(sec 70K Business and Professions Cade The Conractoes Urense Law
r•$ don rrot apply to an owner of property who builds or improves thereor,and
j^ who does such work himself or through his own employees,provided that such OCC-GROUP RES UMTS
Impmvemcw art rat intended oroHered forsale.If,however,thebullding m TOTAL
Improvement 6sold w hMn yearofcompletbn,theowner-buRder"U have
t!, , rdenofpmYI"thrthedld rotbulldorlmprovefmpurpmeolsale.). QTY. PLUMBING PERMIT FEE
LJ 1 as owner of the property,am exclusively ntrxtlng with IberuM FLOOD ZONE APN
m
PERMIT ISSUANCE
contractoto construct the project 70smm and Prafmlons Code:
r 14,Bu
�
The Contractor's I Inuar Law don not apply to u owser al property who ALTER-DRAIN&VENT-WATER(FA) _
WOds or Imp.thereon,and who mmm nfor such p(pocts with a FEE SUMMARY
aQpkaaor(d lfaneed pumanttothe Contraada LicenseLaw. BACK ROW PRM=.DEVICE �
IJ I am exempt under Sec B& P C for this reawn
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_-
V
RCSt]IT
WORKMAN COMPENSATION DECLARATION /.•� #
❑f hereby affIrm that I have a certificate of consent to.eR-Twat or a (/ FIXTURES PER �r `-'�'I •7A% Y N
certifiateof WmIun'CompereaHm Insurance ora cendledmpy thert (Se
ofc. RECEIVE
3800,Lab C.) GAS FA.SYSTEM4 INC4 OUTLETS PARKFEE Y_ N
�' RECTIP 1'#
nry# ON I r_LG ._ GAS FA.S1SfEM-0VFR4(EA)
CoCray J � N a BUILDING DIVISION FEES
VenBied copy b hereby dwith the city GREASEANDUSTAL WASTE INTERCEPTOR PLANCHECK FEE
CenlOed copy b filed with the sty IrepecUon dlvleim.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPFNSATLONINSURANCE
(TMs section need era be completed B the ptroulSURA 6(more hundred dollar SEWERySANITARY-SIORM FA.700FT. Date Recei t#
(8lctnorlead WATER HEATER W/VENT/MrrTR ENERGY FEE Y N
I certify that b the performance of the work for which Bus pemdt is band,
I shall not employ any person in any manner n as to become subject to the WATER SYSTEM/TREATING
Warkuc'Compensation lawn of California. Date PAID
'0 Z Applicant NEW RESIDENTIAL PLMS. SQ.Ff. Date Repel t#
Z O NOTICE TO APPLICANT:I1,.Ber making this Certificate of Exemption,you
should become sub)ect to the Workeri Compewtbn provisions of the Labor TOTAL'
~ 10 - Code,you=9 forthwith amply with such provbbns or Nis mit pershall be
ULTILDING FEE
LU ] deemed revoked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FE
Ihusbyaffirm tMtthere6ammtmc mlerdingagencyforthe perform ELECTRIC FEE
7 Z arce d the work(or which this perout b lastud(Sec.3097,CN,C.)
U O IaMer'a Name PLUMBING FEE
LL F UnAte.Add. QTY. MECFIANICAL PERMIT rFEtv1ECHANICALFEEOW I certify that l have readtMs.ppllotbnard rate that the above Info...
6corrta.I agree to comply with all city ami ordinancescounty ordianand late lawn PERMIT ISSUANCE FEES PAID:). mlatingtobuilding construction,and hereby.uthontre nenreprtativesofthis
F N &yto enteruponme above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
_ (We)agna to saM Indemnify an of keep h.roum the City of Cupertino Date Receipt#
V against OaMOtin,Pd tor,cont,
exp which may In any way accrue AIR HANDLING UNIT(TO 10,00)CFM) SUBTOTAL:
ag as a of u t Ig ami.pmJt. CONSTRUCTION TAX
ALR xANouNc unTr(OVER 10,000 CFM)
-e3 'f CONSTRUCTION TAX PAID:
Signa rtof App loot/Cmtnaor Date EXHAUST HOOD
HA7ARDOUS MATERIALS DISCLOSURE
W me applicant orfutum Wilding occupant store or handle hazardous HEATING UNIT(TO 100,00D BN) Date Recei I#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the —
IieahhaMSafetyC lar 755n(a)i EIGTINC UNIT(OVER 1W,00I BTN
TOTA
❑ Yn aQ��Qallo
Willme applkarI A(uibneWildingoavpantunryuipment ordeWm VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which rout hmardous air contaminant.a.defined by the Bay Arta Ab
® Quality x genie 7 BOBrFCOMP OI-p'OR l00,IXAfUl1) PA N
p
4Yn No D
havc read theh smaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 1(D,f100 BTU)
the CaRfamla liahh&SafetyCode,Seabns 75505,75517 and 7554.I 1 q p,
undestaMthatlfthe WOdingdoeeretcurtentlyhaveaterant,thatltbmy NEW RESIDENTIAL MECH. SOFT VAI Iv 1(1(I
resporaZity to notify the ocapa he requbemeas which must he met 2
pJor rue as Certl(i/cs �° ,ray. `a'
I aG.a-�/U�iQ(�l r /2S=S Z 11(w cup' Ali
Pvnerorauthortsdagent Date TOTAL ISSUEDBY: �JIJ%0
OFFICE COPY