21877 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proeed Identification PIRMIT NO.
Bu lei ng Addrsa:
2a 7 30 ✓A-[_c_� G SEE�J Ok . 21877
TY7.—
+4P Pt E Lo res V CITY OFCUPERTINO BUILDING DIVISION
Cmmci«edam: Lie.Na APPLICATION / PERMIT 1
Cv PE L7 >D E L C C_ , 12YL3 BUILDINGFI.KIRICALPLUMBINGMFLHANICAL GTFLORY CONTROL
Archkeet/Fsglneer. Lie,N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PEMTISSUANCE /�. ❑. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMhSyic.mthatl amhd.3 durderd..rd ProessmuCed, menc APIaLIANCFSRE9DEMlAl JOB DESCRIPTION
Ingme[Satbn70(0)0(Divlsim3 oftha BusiruvandPro(eW ouCode,and my
I Im. le In f u c.11 PANELS 1`
Llesn C m - Lk./ 7
Date CHITS L C .
ARCHITECT SD as publAT10N XVFR 10 ADO MPS
0¢2 I understand my Case ahaB be used u public reowda. OVER 1000 AMPS - SQ.FT.FLOOR AREA 5/SQ.FT.
Licensed Pmfeubml SIGNSEIXZT'RICAL
�< WNER-BUILDER DECLARATION SPECIAL CI1=T/M19C
I., a I herebyafOrmthOal lam exempt fromthe Cordrstlots Lianss law for the
foilowing resum.(Section 7031.5,Business and Professionut Code:Any dty or TEMp.METQtORPOLEINST.
C5 c ntywhkhrtyuB aper wmrutmc"Be lmprngdemoWh.ormpalr
enygaMu pdortoibbsuancealsorequbntheappUantfawchpemdtto POWER DEVICES
fed a signed statement that he is Lernsed pursuant to the proalbru of the
OWI— Cmuralofe Lice.Law CA.Ptn9(onmmendng with Section 700p)of Divi. SINDANCING POOL ELECTRIC
30 alon3ofthe BunnmmdProfes mCoae)or6gheisxmptthemfromaM U TION
Sit the basis for the alleged uemptbn. Any violation of SeGbn 70315 by any
Q pr�j
applicant for a pemdt subjects the applhet to a civil penalty of not room than TSSWCICI-IESFDCNR6 o
IWhundrtd dollue(5 M.
Ni,as owner of tM property,or my employers vot h wages as their wkNEWRESIDEMTALF.T TR SQ.FT. STORIESCONSTRUCTION
compamation,will do the work,and the atromb not t UM
deed or offered for
p vk t5ac7004,Buttress and nla
and Prv(em Code:The Curdraora Umme w
n
[ $ doneat apply town owner dm
ppertywho builds orimprovea thereon,and OCC.GROUP RIS.UNITS
P• who dmeuchwork hlmeelfor through wowneerpigen,provbcd that uch
Improve amnmintendedorofferedfmule.l4however,thebuildingor TOTAL r40
�
Improverrcnt h add wdhln oreynrofmmpletlon IM owner-lou Ilder will have
t1Rrdenofprovingthabeda tbRBdorw,pr fR porpR ofma .). QTY. PLUMBING PERMIT FEE
LJ 4 ae worm of the Property,am en mrcwh•ely cowntracting ),Ikrnsed FLOOD ZONE APN
onntractoto rutrtl uthe project 7014,Rueneae and Professions Code: PERMITSSUANCE
TM Co motor:Lumnae Taw dm not apply to an owner of property who ALTER-DRAW 6 VENT-WATER(EA)
IstBamr
s or improves thereon,and who drem for aueh projecM1 whh It TFEE SUMMARY
dor(a)Limmad pursuant to the Cmtratlers Limnse Law. BACK FLOW PROTECT.DEVICE
J I am exempt under Sec. B k P C for this reason
Owner ot.�TSI DE FEES
Date DRAINS FLOOR ROOF,AREA,OOND. SANITARY Y N_
RECEf1T A
WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP SCHOOL TAX Y_ N_
❑1 Mrty affirm that I have a certificate of concent to self-Insure,a a
(.,wflateof Workers'C.Pe.t Imunna ce a certified copy themof SSee RILFII'T
3803 Lab C,�, GAS EA,SY51EM-1 WUOUTLETS PARK FEE Y_ N_
PR1Icya fC 9906s'3 RF.CEIT8
Co an�_C��a �A CAS EA.SYSTHa(-0VER4(EA) BUILDING DIVISION FEES
I Certifies copy ea Medi Nath the city
GREASE/WDUSrRL WASTE INTERCEPTOR PLANCHECKFEE
IPSIIS cerllRad copy 6 riled with the dry wpeNon division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRAP 'PAID
COMPENSATION INSURANCeSEWER-SANITARY-STORM EA XXIFT Date Recel t#
(Thbsectlon need norIx completed if the permit Ester one
IT
hundmd dollam
(St00)o:less.) WATER HEATER w/vENr/E1.EcrR ENERGY FEE Y N
I¢uuytM1N in the perform nceorthe work forwMch this permit hone
lsd,
1 shelf not employ any person In any manner ro n to become aabjeetto ted WATER 5YSD7dlfREATING
Workers'Copnaatbn laws of Glifarw.Date PAID
mn
Date Recti t#
LICE
Z � APP NOTICE TO APPLICANT: ma"If.after uutide CertBkate of Eremplion,you
NEW RE9OENTIAL icant PLN B' SQFT.
should become subject to the Warkera'Compemrt{on proaisbro of the Labor TOTAL
Ln Code,you nustfarthwith comply with arch provisions or this permit shall be
W > deemed revoked.
CL G CONSTRUCTION LENDING ACMCY 15EISMIC FEE
I herebyalBrmthe there b aconetruddon kMingagency fortke perform TOTAL ELECTRIC FEE a
7 Z anm of the workfor which this permit is Wued(Sec-3097,CW.C.)
OO trMer.Name PLUMBING FEE
LL F Lander:Add rcaa QTY. MECHANICAL PERMIT FEE MECHANICAL FGE
O W Imrtltythetl Mve rcedtwappBratlonard latetFuttMabovelnformation
1 hmrrecl.I agree to comply withall city and county ordlnancssnd nate lawn PERMIT ISSUANCE FEES PAID.
} N relating to Wilding ooremGloo,and thereby autho repremntatives ofthls
dt to enterupon the above-mentioned for W ion ALTERORADDTOMBCH.
~ ? y(We)agree o save,Indemnify an a keep h leas the City o Cupertino Date Recd t#
V ago wtke,pagmema,mns.rw experuss welchm In.nyw,y.mve AIR HANDLING UNIT(IO 10,000 CPAU SUBTOTAL:
a Iroise CuyJn eemaeq , itM goof ofthis d.
AIR HANDLING TWIT RAVER 10,000CEM) CONSTRUCFIONTAX
Sig /Applo r W
CONSTRUCTION TAX PAID:
HAZARDOUSIMATERULSDASURE Cut S ( / )
or HEATING UNIT 100,000 BTIn
Wia the apped bythutuprtinoM rddp Code,
rthapterhandlehaurdthe Date RCCCI t#
materialas defined Code
Cupertino Murdtlpal Code,Chapter 9.11,and the
IkalthaM Safety code Stolon 5531W7 Fff.1'M•G UNIT(OVER 100,000 BTU) T L: O
❑Y. No
Willemit happlicartrardu r contaminantsdLog as defied by equthe lay nt AreI dealers VENTILATION FAN 151NGIE BESIDE I$SU TE
which eMt ha enema air contaminants u defined by the Bay Arca Air
Quality Managemerd Distttct?No BOILER-COMP 100,000 BTI71
❑Yn No M
Ilhave ol,t ealm�oue Codle, ertqulreme5,25D3under
and 25534.95 of BOILER CbMP(OVER IW,OW BTU)
the Callfomh &Safety building
Coda not
untlyh 25D3 and Shat It
undcmlaniftyto t t bulecceu oes teat currently men atenant,tlutlthrty NEW RESIDENTIAL MECH. SQ.Fi
rm Illy tR nallfytheompard oft rtqulrtmenta which neat be met
aorto uaaceofsCcrtlb of nry.
r authoNrd agent late ISSUED BY: �P
TOTAL:
OFFICE COPY