22019 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identmcation PERMIT NO,
Building Add.,: LN. (•} /V • 2201 ^
Z y r G G �V.I
r'h
PAr4L /its-L.As/U (- T _nep CITY OF CUPERTINO-BUILDING DIVISION A 1 -2
f C'/'�Q 2
contract°r. am: Lic.N°: APPLICATION / PERMIT d C
O ZO' Z UI
BLDING-ELECTRICALPLUMBING-MECMMCAL CAHCO Y CONTROL pia y�
Architect/ gineer. Lic.No: �7 �•i
LTJ v 2 BUILD ING.PERMIT INFO
QTY � ELECTRIC PERMIT PE•E°
Address: Ia A/I /"40 4440 PERMITISSUANCE•
LICENSED CONTRACTOR'S DECLARATION Tr77��)) --
Iherebyafflrmlhat l aceLcenand under previsionsof Chapler (r�m712 c APPLIANCFSRESIDENTIAL JOB DFSCRE' ON
Ingwith5 dion7000)of Divielon3oflhe Buelnemand Pmfeealon$Code,andmy
license le In full force and after. PANELS Poo
LlcenseC as Lic.a
Dale L Contractor OW S —LM IQ 20Q AMPS
ARCHITECTS DECLARATION 201-1000AMPS
q�+070. Iu nnland plays Il be used as public record OVERIOOOAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
d� Lice P t'll"1 SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION
rn SPECIALCIRCUIT/MISC
72-5owingyafoone n. Seat ctonmexempt 31.5,B(mmthe sandPtnctsion.CmsLwfoyhe
county following on.iredlonrmitto onstruel and Professions Code:Any city or
O H� TEMP.METER ORPOLE]NBT. '
��
county rcqulresa pemdltotorotrud,alter,Improve,demolish,orrepalr
t anyetmdumpAortolis Wuance,alsorequimtheapp0centforsuchpermltto )OWER DEVICES
P� file a signed statement that he Is licensed pursuant 10 the provisions of the
o63µ, Contractors License Law(Chapter 9(conurendng with Stolon 7000)of Divi-
,_,SOS alon3ofthe Buelneas and Pm(embro Code)orthrt he la exempttherefromand "1NG
'wF'OOL ELECTRIC VAL 77ON
�5dp+ a the basis for the alleged exemption. Any violation of Section 70315 by anyOUTLETS-SWITCHES-FIXTURES /
0 appH..tforapnr .b*e th.appUcantt.advilpevltyan...than a
flue hundred1,asoowndoler
of the pr). NEW RESIDENTIAL ELECTR SQPr. STORIES I TYPECONMUCT 0N'
�n ❑I,as owner of the property,or my employees with wages as(heir sole
rompenea 044,B.iomathe work andthe sC cle:Th not lntartoe o License
d(or
O sae(Sec. ppy to ainowand f property Code:The or imp dors Llceron law
@ docs not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES UNITS
EE whodoei each are not mtededowgh Matisse employees,If,han, er,thedthat such ildingr
Improvements arcnotintended earofc p101oe.If,bowevey deer ill have
tmprovementbaoldwithlnoneycarofcompldiorythe owner-bu0derwill have -
t)Ltiurdanofprovingthat he did embuildorlmprovelmpurpoaeo!sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constred the project(Sec.7014 Business and Pr°feselors Code:
The Contractors License Law does net apply to an owner of properly who ALTER-DRAIN&VENT-WATER�A)
Wilds or imprw
ea thereon, and who contracts for such plojeda with a _
co8actor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE. FEE'SUMMARY
I am exempt under Sec. B&P C for thb recon
OITTqinrrr
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION re FD(']URES PER TRAP SCIi00L TAX Y N_
❑I hereby orlous that I have o Insurance
nsu a c of consent t°copy
then ora RECEIPT p
3801llceteofWorken'Compersatloniruunnce ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380Q Isis C3
Polityp RECEDING DI VISION FBI:.
CAS-EA.SYSTEM-OVER BUILDING TN
Com any S
01Bea copy is hereby fuMte,,d - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
e01(led copy Is filed with lbe city inspection division. - /
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID s
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi tM
(This radion need not b completed If the pemdt b lorone hundred dollars
(5100)rtifytJ WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N
I llnet emplohat In y
he any person
In any
thecourser
so an to become rmit Is
issued, —
I shall not employ an/person In any manner ao u to become subject to the WATER SYSTEM/TREATING
W°plican Compcneatlon Lawn o(GIIlornb, Data PAID
O Z NOUCnt NEW RESIDENTIAL PLMB. SQFr. Dale Recei tN
shoulZ p NOIICbacmeaPLICAM:IL cher mWompe Ction prevo molt elao
Code, become subjectto theplywit'Compemasonprovbiorsofthe Labor TOTAL:
W y dedgyou olsed.forthwith comply with each pmvbloro orMb perMtshall be BUILDING FEE
W deemed revoked. '
Qa�'gTRUCTION LENDING clwcY SEISMIC PEE a
d IhercbyalRr t the re b a comlrodion a ingagenry for the performs ELECTRIC FEE
7 Z ance of the work(orw ch this permit is issue Sec.3097,Cle.C.) I
U O lander•.Name PLUMBING FEE
LL Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifytbatlhavereadt appU.tt andstatethatthe above lnformtlon
4 bcerrcd.Iagreetocomplyw all and county ordinancesand orate laws PERMIT ISSUANCE FEES PAID:
} to relating to building mmtrodion, hereby authorize representatives of this
)— Z city to enter upon the shoe oo roperty,for Inspection purposes. ALTER OR ADDTOMECH. Date Reeei [q
_ (We)agree to save,Inde Ify and hamdess the City°f Cupertino
against liabilities,judgme ,costs:ndexper. may inanywayareme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against sald it in on a..of the granlar a pe
�$ AIR HANDLING UNIT(OVER 10,(00CFM) CONSTRUCTION TAX
gets reof Applicant/Contractor to Ex7AUs r HooD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 41
Will the applicant or future building occupantstore or handle hazardous 1 HEATINGUNITGOl00,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ` __ Date Recel td --�R�—
HfealthandSafmyC°de, ion2S532(a)7 HEATING UNIT(OVER o 100,000 BTU TOTA L�
F1 Yes No
Will the applicantAnt building occupant use equipment or devices VENTILATION PAN RESID) ISSUANCE DATE
which emit hazardous air conlamlmnts as defined by the Bay Area Air
Quality Management Det 7 BOILER-COMP OHPOR 100,000 BTU - R� p
A4Yea o ID '
hay.m1athe haze amte0ab requirements under Chapter 6.95 of BOILER-COMP 1f0,000BN)
P
the Calltornla Iicallh&Safety Code,Sedlon.25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECO. SQ.FT !AUG 14 igg2
re.p°mibllity to notify the occupant of the requirements which must be met
Prior too a nee daCertiticeteo Occu anp ry.
(�i�s/�yl{ja�< /1/'`�•+•iA"Ll�fa—'�/,/ 4e
CIT,'
raulho0aed agent " Daze - � 7$gUF-D BY:
OFFICE COPY