20487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: /1 o A n
],OG7bO VF1�-1_� GR A mQ$, G 4 v(
nerd ante: one: APPLICA11ONSURNHIA17=A -
CITY OF CUPERTINO-BUILDING DIVISION C?0
c ^trado aN me: Lie.No: APPLICATION / PERMIT L
BUILDINGELECTRICALMLTMBING-MECHANICAL CATEGORY CONTROL�OJ'Z
Architect/Engineer. Lt.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO'
Address: 4149 LC.,7 r � PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflren that l am licensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL JOB DESCRETION
ingwith Section 70M)of Divist^n3oflhe Businenand PmfessionsCode,and my
licenses in fullfo and effect. 1 PANELS
License Clase�Lic.p
Date_'?—/ Contractor T
ARCHITECPS DECLARATION 701-1000 AMPS
flZO Iunderstand my plans shall be used as public records. OVERIOOOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
0 Licensed Professional SIGNS ELECTRICAL
�G c OWNER-BUILDER DECLARATION
pN SPECIAL CIRCUIT/MISC I
1.., Thereby of ..(Sallamexemptfroess. dPrefeedim. ode:Anydtthe
OZ2 following reason(Sedlon 7QilS,Business and Pm(enlona Code:Any dry or TEMP METER OR POLE INST.
f' c ntywhichrequlresaperndttocomtmdL ter,lmpmve,de=H h,orrepair
�`'B�Cci anystructure pdorlo its Issuance,alsorequires theappliwnt forsuch permit to '
V POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
O t. Contractors License Law(Chapter 9(comen
mcin with Section 7000)of Divi-
,�Otn sion3 ofthe Businessand Pmfcxdmv Code)orthat he is exem therefromand SWAihIING POOL ELE VALUATION
in<s the.basis for the alleged exemption. Any violation of Section 70315 by any -OUTLETSSWITC
applicant fora permit aubjeds the applicant to a civil penalty of nat more than
a.�o five 1,as
owner ofdollars
NEW DEMIIALEL SQ.FT. STORIES TYPE CONSTRUCTION
? n ❑I,as owner will
the property,or my employees with wages r there dole
compensation,Business and
and the ions Code:The
Vnot intended or offered for
Osale(Sec.70E4,Business and Professions Cade:The Contractor's License law
3$ does not apply to an owner of property who builds or Improves Ihereon,and OCC.GROUP RFS.UNITS
who doessuch work himself orthrough hisown employees,provided that such
improvements are not Intended or offered for sale.If,however the building or - TOTAL:
ImprovementlasoldwRFlnoneyearofcompleion,theowner- flderwillhave
the rden of proving that he did ret build or improve for pu rpose of sale.). FLOODTDNE APN
�u QTY. PL MI FEE
Li 4 as owner tr the property,am exclusively Business
and Professions;
licensed PERMIT ISSUAN
contractors to construe the project(Sec.apply
Business and of property
Code:
The Coor Impr'a License law dcea nae apply m an owner of property who '
Wilda or imprwn thereon,and who contracts for each plajects with a ALTER-DRA' -WA
.FEE SUMMARY
m,Ltt(factor(sexempt under Sec.
the Contractor.License Law. BACK p(p1y pR0'I'FLT.DEVI
' LJ I am exempt under Sec. B k PC for this reason
R OUTSIDE FEES
Owner Date DRAINSFIAOR ROOF,AREA. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT X
FI%TIIRFS PER TRAP SCIiODL TA% Y
❑I hereby affirm that I have.cortlf tete of consent to self-Insure,ce a _ N
certificat:of Workers Compensation Insurance ora certified copy lhemcf(Sec. RECEBT X
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
RECEBT N
. . 'Policy# GAS -OVER4(FA)
Co ny BUILDING DIVISION FEES
dCertified copy 6 hereby furnished. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is filed with the city Inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOFf. Date RCCCI t#
(Thlssection need not W completed lithe permit for one hundred dollars
($100)orlen.) WATER ITFATER W/VFM/ELFCTR ENERGYFEE Y N
I unify that in the performance of the work forwhich this permit is issved,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of Califomla.Date PAID
O Z Applicant NEW RESIDENTIAL FILMS. SQA. Date Recei t#
Z O NOTICE TO APPLICANT.If,a her making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
!A .Code, a most forthwith comply with such provisions or this rank shall B ILDING FBG
j deemerevoked.-
CC "sem
d
CONSTRUCTION LENDING AGENCY' SEISMIC FEE I O
(L I herebyafOrmthauhem bacenstruction lendingagency for the pedorn, TOTAL: ELECTRIC FEE.
7 0 me ance ofthe work for which this permit b isatu,di ec.3097,CIv.C.)
Iander.Na - - PLUMBING FEE
LL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mrtifythatllavereadthuapphI tionandelatethattheaboveinformation
a Lscormet.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereby author ite reprexntatives of this
N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? lWe)a c to save,indemnify an d keep harmleas the City of Cupertino Date Receipt#
V against Ilities,µd nt s and expenses which may In anywayaccme AIR I LANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal City in n ence a(the anting of this pe 't.
�+ AIRHANDLINGUNTT(OVERIQOOOCrix) CONSTRUCTION TAX
curare of AppBcant/Contactor Date EXHAUST xooD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA ERIALS DISCLOSURE
Wllltheapplicant or future building occupant store or handle huardoue HEATING UNIT(TO 100,000 BTU) Date Recel t#
matedal as defined by the Cupertino Municipal Codc,Chapter 9.1;and the
Health and Safety Cion 2S532(a)? HEATING UNIT(OVER 100,(3130 BTII) - TOTAL:
❑Yes o
Will the applicant tore Wilding occupanl use equipment or deviccs VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emitbvrdous ircomaminantsasdefiu bythe Bay Area Air -
QualilyManagementDist d? BOILER-COMPOHPORIW,O(q BTU)
4Yes o
have read the hp oua materials requirements under Chapter G95 of BOILER-COMP(OVER100,000 BTU) w-_—
theCalifomiaHealth Safety Code,Sections 2SSU5,25533 and 25534.I I
understand tlithe building does not currently have a tenant,that it to my NEW RESIDENTIAL MECH. SQ.IT.
responsib' ty nat ifyt no(the requlrcmentswhich must be met �)
prion ce ofd rt10 to olOmhpancy.e req - kj. h I0CU
Owner or authorised agent Dns TOTAL: ISSUED PFtftlill�
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildingk.W
Project Identification L PET NO.
Building Add � _ - 21802
1 n O G
n
vers o% one: A .17 A A
[� A-rIse Irq S 2 ke^I$-I CITY OF CUPERTINO-BUILDING DIVISION
cnno-attn:ana J LIcNo: APPLICATION /PERMIT
Z.A. LONd7'QUC17O BUILDING-¢ECTWCAL-PLUMBINGMECHANICAL CATEGORY COhyPR (P2
Architect/Engineer. Lk.No: lJ t0
QTY ELECTRICPERMIF. FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE C.� � Li
CONTRACTOR'S DECLARATION
I hereby aNhm that l am licensed under provisions of Chapter 9(commenc APPLIANCES RESIDENTIAL J08 DLSCI ON
ingwlth Section 7000).!Division 3ofthe Bust nes,and PmfesslonsCodp and my
license Is in full to.and effect. _ PANELS ^�""�
License Class Conte Il
Dale Contractor —UP TO 20OAhU
ARCHITECTS DECLARATION 201-IODDAMPS
qqqP 2 I understand my plzm shall bs used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA �$/^SQ.FT.
00
a d o Licensed Professional SIGNS ELECTRICAL JL�a co
< OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MLSC ""-'iii•••'
e-ev�f 7 I hereby affem that I am exempt fmmthe Contractor's License law for the
z,
p following reason.(Section 7031.5,Business and Professions Code:Any city or
07,I.µ9 TEMP.ME[7R OR POLE[NST.
countywhkh rcqulres a permittomnsWct,alter,Improve,demolish,orrepalr
anystructure prlorto its Issuance,alsorequves theapfficant!.retch permit to POWER DEVICESr
Q U file a signM statementb
that he licensed pursuant to the provisions of the
3 q Contractor's License law� (Chapter 9(...cinwith Section 7000)of Divi-n g MI
SWIMNG IDOL ELECTRICFOS slon3of the Business and Professioro Code)orthat he Vexempt there(mmand VALUATION
the basis forthe alleged exemption. Any violation of Section 7031.5 by any
4 a l l' ours cTssw TCF ESFTXTUR s �^
❑(� livehandreddollars apelMt$500).sthea]ipikanttoacivilpemltyofnotmorethan Sot W
�?¢
F1 1,as owner of the Property,or my employees with wages astheir sets' NEW RESIDENTIAL ELECTR SQFf. STORIES TYPE CONSTRUCTION
compensation,wfI dothe work and thestmcturc b not intended or offered for
5 O sale(Sec 7044,Businessand Professions Code:The Contractors License Law
-2 does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNITS
who doessuchworkMmreUorthr.ugh his.wnemployces,provided that such ,
improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement usold wilhinoneyearofcomplelogtMowner-b OderwBl have
thLkiaden of proving that he didrwt build or improve for purpose ofsale.). QTY.I PLUMBING PERMIT FEE FLOODZONEAPN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to com uct the projM(Sec.7014 Business and Professions Code: 2 a
The Contractor's License Law does not apply to an owner of property who ALTER DRAW kVENT-WATER(EA)
builds or Improves thereon, and who contra for such ptojecte with a FEE.SUMMARY
,,Il5S(ador(s)ficen,ed pursuant to the Contractor's License Law. gpIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this rca,nn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_.
• Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION PER TRA[' TtLauSCHOOL TAX Y_ N_
Fereby a((Irm that I have a certificate of consent to ul(-Insure,or RECEIPT a
ce i@ateofwb C.)
orkeri Compensation[raceurance oracertifled copy thereof(Sec. GAS M-
EA.SYSD1 INCA OUTLETS PARK FEE Y N
3 ,la _ _ RECEIPT p
Policy x GAS EA.SYSTEM-OVER 6(EAJ
Com any - BUILDING DIVISION FEES
copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy d filed with the city inspection division. ti
GREASE TRAP �y� 1
CERTIFICATECOMPENSATION
I N FROM WORKERS' PAIDZ�.J l�L ^�f p
COMPENSATIONINSURA.NCE SEWERSANFCARYSTORM EA.200FT. Date Recei tit
(this section need no be<ompldedd the permit V(prone hundred dollen
($1000 or les.) WATLR}[EATER w/VENT/¢FOTR ENERGYFEE Y_ N
I certify that In the performance of the work for which this permit is Lwoed,
I shall net employ any person in any manner so as to become subject to the WATER SYS INN/TREATING
Workers'Compensation laws of California. Dale PAID -
z Z Applicant NEWRESIDFN'ITALPLMB. SQPT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the W.rkeri Compoaa ion provisions of the Labor TOTAL:
CCCode,you must forthwith comply with such provlalomorthispermit shall be BUILDING FEE 1 .6U
W _ deemed revokes.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. O
I hereby affirm that there E a construction lending agency for the perform- TOTAL. ELECTRIC FEE
:) Z ance of the work for which this permit u finned(Sec.3097,Civ.C.)
00 [.notes Name PLUMBING FEE
LL r I.nder'sAdd.ss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W re
l certifythat T have read this applicationand statethat Neabove Information
a is cod.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives ofthis
F N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V' agaimtiiabilltk.,j,dgments,comsandex erases which may In anywayacarue AIRHANDLiNGUNTT(I'010,000CFM.) SUBTOTAL:
against Id Cityln con sequence the gr etingofthlspermit.
AIR HANDLING unTr(OVER lO,Im CFM) CONSTRUCTION TAX
Sigrature o(Ap ant)Contrattor 1/�tY� MIAUSTHOOD(W/DucT) CONSTRUCTION TAX PAID;
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
health and Safety Code Section=W? HEATING UNIT(OVER IOQOW BTU) TOTAL: �-
rj Yes NN.
Will the applicant or future building occupant use equipment ordevices VFNDLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contarel ants as defined by the Bay Area Air air.
Quality Management District? BOILER-COMP 011P OR 100,0(10 BTU) AM
❑Yes ❑No PAM 11
. [have read the M1 rdous materials requiremtnb under Chapter 6.95 of BOILER-COMP(OVER 10a,"BN) /ID
the California Health k Safety Code,Sections 2550.5,2 SIO and 25511.] APR
understand that i l the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT. r7�I
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. of
Owner or authorized agent Date
TOTAL: ISSUEDBY:
OFFICE COPY