21604 (2) r'
NarrLllaAlY I iv rILL IIn1 Flvrvnnl/1N wNv I-1 `-/ '
Building Frowt Identification PITMTNOO. O4
.
Building Addrusv ./ A
� 1 `I I 13ouI-I rJ 6- z I �c3 oND G
'DWWer. ami:
Yr J !�L.t_o Q R 5, Q CITY OF CUPERTIN0.BUILDING DIVISION
.antmctm'.Name: �^ Lk.Na: APPLICATION 11. —
`' A� �YW cal —� BUILDING-ELECTRICAL-MUMBING-MECHANICAL CATEGORY C M
ArchiN ct/Engineer. Lk.No:
RE R y r' '"N m ,r' "' BUILD C PERMIT INFO
Q'rr ;1... a A ELECT•*PERMt ' +.i" A. FEB.- -•,=. -
Addrees: PERMITISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby.(firmthat lam licensed under provisions of Chapler9(mmmenc- AI'1'WANCESRESIDENML Og D,ES1C�R,E.'�niIIIOON
Ingweh in fultlonl
force of Divfect. the Buslrua@and ProleuloneCode,and my
Ikenn b ecfun loroe.nd dfed. PANELS \\\
Llnnse Class Lk.N
Dale Contractor fi11000AMI5
ARCHITECTS DECLARATION
SIO l understand my plans@hall be used u public records. OVERI000AMIS SQ.ET.FLOORAREA 3/SQ.IT
{ELicensed P,of,.Wul SIGNS ELECTRICAL
!! OWNER-BUILDER DECLARATION
In @ SPECIALCRRCIIIT/MISC
p, 5 ,hereby affirum.(that l am 31.5,Bxempt from s a d I'mfesslo License Law for the
Q falWwing mum.(Section 7031 S,Business and Profeubns Cade:Any ally or
uI county which requires a permit to construct,alter,improve,demollah,orrepalr TEMP.METLR ORPOLE IN57.
�E 7 any alrudun statement WuauIs gabe rc d prumu tat to the provisions
of t e POWER DEVICES
K Oleaactors icnseLa,hathetlicensed enclegtit the pon 700M f the
��rq Contndor's License Lew(CMpter9(commencing with Section 7000)01 qvl- SWIMNIING POOL ELECTRICn VALUATION
1 alon3olthe BuaneuandPMculonsCode)orlhat henvemptihercfromand �y
G the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETSSW,TCHmr
ESFIXTURES CfO �/ �-//
applIcant fora permit subject,the applicant to a civil penalty of no
ore than 0
flv61,undred dollars(S500). - NEW RESIDENTIAL ELECTRSQ.FT. STORIES 1YI'ECONSTRICTION
�n as owner of the pmperty,or my employees with wages as their solo
CC compensallon,will dothe work and thearucture Isnot Intended or offend for
psale(Sec.7044,Bushaeasand Profeselom Code:The Contractors License Law
$ docs not apply to an owner of property who builds or improve@ theme,and OCG GROUP RFS UNITS
whodoea such work himself or through hiSOWA employees,provided that such
Improvement.are not Intended oroffered forsale.If,however,Ihebullding or TOTAL: Vr50
Improvement Issold within oneyearofcanplNlon.theownerbullderwlll have ;y^' p
l"rden of proving that he did not bundar improve for purpose of sale.). yta. ":^,;:"PLL<MBWCP I( 1T-:r^�+1' E`; FLOOD ZONE APN
L-1 L as owner of the pmperly,am exclusively contracting with licensed ppJ(MIT ISSUANCEmnindan to..truct the project(Sec 7044,guinea and Professions Code:
The Contractor's License Law dm not apply to an owner of property who ALTER-DRAIN k VENT WATER(FA)
builds or Improves thereon,and who contracts for such p,ulecta with a ' ''.FEE SUMMARY
cj5ador(@)Oanaed pununt ro the Contndoes Lianw Law. ^3.":`I(":':`e"
LL�J I am exempt under Sec. B 4 P C for this reason BACK FLOW PROTECT.DEVICE
OUTSI OF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dae RECEITT N
WORKMANlh.v..COMPENSATION DECLARATION FIXTURES PER SCHOOL TAX Y_ N_
QI hereby affirm that,have o ceaOMate of conrem to opytnsun,ora RECEIPT N
38W,Iateol Worken'Compensallonlnaunnceora artifled copy ihenmf(Sec. GAS RA.SYSTEM-i INCAOUTLETS PAR Y N
Policy
a CJ -
Ib11ryN —t
INGDIN
Ca�mp�ray � GAS G.SYSNM-OVER1(RA) BUILDING DIVISION FEES
I ICer110ed copy Is hedwith ne city GREASE/INDUSIRL WASTE INTERCEPTORCIIECK PFS
Csettled copy Is herebyllhthesty Inspection division. �� �[�'/"��I CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP 1 �"1COMPENSATION INSURANCESETVFR-SANITARY-STORM EA 200Rf �/—Date Revel 1p(Thlasedion need rad hcomplemd Ifthe permit Isformehundreddollar(f1Im"ifyes.) WATER HEATER W/VENT(ELUCTRGY FEE Y N
Iceor has.at Wtheperfomunn cal the work forwhlch this permit is Wooed,IshallnotemploynayperamiInanymannermuto be ome mJ to the WAq�SYSTEM/TREATINGWorker Com ya�Ion ya spl Califq��s Dale Q Z Applicant �(��-Sb w/l r '/a�+U NE'W RESIDENTIAL PLM8. SOFT. Date Revel t#Z 0 NOBCETO APPLICANT:If,after makdngthttCertlfialeof Exempllon,you.hwldbecomesubject to the Worker'Compensation provisions ofthe Labor TOTAL:
nCodeyou mustfonhwithcomplywilhwchpro lo"orthispermitihalibe
W j domed revokd. INGt1C CONSTRUCTION LENDING AGENCY IC FEEl hereby affimChat there Is e coutrudlon lending agency for the perform TOTAL: RIC FEEO anon of the work for which this rmit Is issued(Sec.3097,CIv.C.) BING FEERlender's Name LLLendersAddress IY.>M� _1NH� fAN[CAL�PER(v�ITg�;?. ANICAL FEE
OW lcertltythali hvereadthbappOalionandaatethaltheabovelnforoallonIscumd.l agree to complywlth all cityand county ordinanm and elate laws PERMITISSUANCE r.N reI.tlrgtabuidI,Sooutrur1I. ,.nd herebyanthornerepmaentallvuofthIs C't�city to enter upon the above-menlloned property for lupedbn purpox.. ALTER OR ADD 70 MECH' ate - Revel tp
— (We)agree to save,Indemnify an d keep harmien the City of Cupertino
against liabilities,Fadgnomt,ccau. d upenanwhich may lnanywayaaroe AIR HANDLING UNIT(170 10,000CFM) SUBTOTAL: -
against said City lnconsequence ofthe granting of this permit. AIR HANDUNGUNIT(OVER 10,000GFM) ONSTRUCTIONTAX
Slgnatu n of Applicant/Conlrador Dole E(1 IAUST 1100D(WI DUCT) NSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE I-
Wllllheappllcantor future building occupant stare or handle haeardous BEATING UNIT CFO 100,000 BTU) Dae Receiletfl
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the - -
I fish and S.(My Code Section 25532(.)7 BEATING UNIT(OVER 100,000 BTU,) TOTAL:
RYes L_I No
ill the applicant or future building occupant use equipment or devices VFNTILATION IAN(SINGLE RESID) ISSlrr MATE
which colt harardom air contaminant,as defined by the Bay Area Air
t'r'J�'�Y1B
• Quality Management District? BOILER-COMP OFR'OR 100,003 BTU) r�
❑Yea Q1�1No ,JA QQ9y�
' ,have read the hazar`fi ossa materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU)
the California l lulth k Safety Code,Sections 25505,25533 and 25531.1
u oderstd!that if the bu llding don not correnlly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.rF jN1ar�,�rk
responsibility to notify the occupant of the requirements which must be met q `� W
prior to Lauance of a Certificate of Occupancy. 1{JRy �"C�^-
Owner or authorlredagent Data gSUp01/
TUTAL
OFFICE COPY