21752APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project ldenOflutlon
Building Address: p �
O CT a O T %/ 0 L'R�v 3 � 11- 7—
PERMIT NO.
f")'I l5 r Gr%
G I
are. one.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MECPUMCAL
AP7�11UN SUUMII IAL UAIE
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Contractor. name: H Llc. Na
�� D oCATEGORY
CONTROL N
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Amhl /lsglneer: Llc. No:
S ' ti/
Qct. ELECTRICPERMIT FEE
BUILDING PERMIT INFO
BLUG ELE
Address:
PERM TISSUANCE
g xJ '
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pronisions of ChaPbr9(mmmmc
ingwlm5edfull 7000).( Dieffeet .(the Busineaand PmfessionaCode,And my
limnx bin full fo dd(ect. J�
Llcenx Claaa=t,# —/ 3 o e) -
Date Contractor
APPLIANCES -RESIDENTIAL
]OB DESCRIPTION
J
PANES '
201 -IOM AMPS
OVER 1000
ARCHITECTS DECLARATION
Iurd,esUrd my plamahall be used a public ramrds.
SQ. R. FLOOR AREA S/$.Ff.
SIGNSEL C
SPECIALC T
Licensed Professional -
OWNERBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
3 3
TFMPMETTlt NST.
following rtason.(Sedlon 71lt.5, Buslne»and Profexlom Code: Any airy or
county which requlrssa Permit tomtruct, alter, Improve, demolish,orrepalr
( G�
anyswdure prior?. lb tsauance,also orylresthe appBcant for such permit?.
file a .locoed statement that he islicensed pursuant to the provisions of the
IKri1,ER-DEVICES
J O
SWIMIANGIWLELFCTIOC
Contractors License Law (Chapter9(mmmencing with Section 7000).! Divi-
slon3 of the Buolnesaand Prole»Wns Code) orthat he b exempttherefromana
VALUATION
theIS for the alleged exemption. Any Wolatl.n of Section 7831.5 by any
applicant for a permit eubjectathe applicant to a d") prrulty of not more than
OUTLETSSWITC[iFSFIXTIIRFS
-/ Y5 -
NEW RESIDENTIAL ELFCTR SQFf
—SQ.FT.
five hundred dollars (f5001.
❑1, as owner of the property, or my employees with wages a their sole
SMIUIS
TYPE CONSTRUCTION
compensation, will dothe work and the structure is not Intended or offered for
sale (Sec. 7049, Business and Pmfesslons Code: The CmAradora License Iaw
docs not apply to an owner of property who builds or Improves thereon, and
who dons through such work himself or thrgh his own employees, provided that such
OCC.GROIIP
PIES. UNITS
Improvements are not Intended oroffered formic. I[ however,thebullding ee
Improvement b sold within oneyear ofcompletion, the owner-builderwill have
TOTAL:
thpkurdenoTrm,Ing that hedm notbpnd orlmprove fwpurposeofsale.).
LI L as owner of the property, anteacluaively contracting with licensed
me0adors to construct theP oK 44, ct(Sec. 70Business and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractor's License law dm not apply ct an owner p property who
Wilds t Improves thorn, And who tractacv for such p.ojem with a
m,,BRl{1actOm exempt under Secnt . the Contractor's Llunx law.
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN VENT- WATER BEA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONE).
SAMTARY Y_ N
RECEIPT N
Owner - Date
WORK MAN COMPENSATION DECLARATION
hereby affirm that I have o I r uranc .f consent to op therm, ora
certificate
un0,Lab of Workers Comperuatlonlnsuranueeacertified copy thereof (Sec.
,of lab CJ
N
FIX7URESPERT'RKP -
SCI100L TAX Y_ N—
RECEIPT N
GAS EA. SYSTTM-I INCA OUTLETS
PARK ITE. Y N
PT N
GAS FA.SYSTEM-0VFR4(FA)
Conry
Com
Com any %�f ii �.-rT-/ s �
DING DI
BUILDING DIVISION FEES
ropylsherebyfumished.
p7�Cenlfied copy is filed with the city Inspection dlvlslon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
I GREASE TRAP
i� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCESEWER-SANITARY-STORM
(1'hlnauction need notMENSATI Nthe SURA ls!Drone hundred dollars
PAID
Date Remi t#
'
��G
EA. 20OFT.
WATER EIFATEe w/vENrr/FLECTR
ENERGY FEE Y_ N
(S100)eef
tmrtuythtnat in the performance e To.mco
unreortne work for whirrs b B
pemmbla.ed,
WATER SYSIEd/TREATING
I shall not employ any person In any manner n a to become subject t. the
Workrrf Compenatine lawn of C.Ifo..Ia. Date
PAID
Applicant
ISIAIaPLICAM:IL after nuking this Certificate
ate of Exemption, you
RESIDENTIAL PLNB . SQ.FT.
Date Remi tic
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TOTAL:
,
should become subFd t. the Workers' Compensation provisions of the Labor
Code, you most forthwith mmply with such Emulsions or this permit hall be
deemed revoked.
BUILDING FEE
_
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffim,that there It a construction lendmgagenay forme perform
once of the work for which this permit is issued (Sec. 3097, Cl, C)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
70,
Landre.N.me
Lander',Add.
have mad this applicationand Mate thrtthe above Information
iscorred.Iagree to comply with all city and county ordinances and slate laws
MECHANICAL FEE1renlfythatl
PERMIT ISSUANCE -
FEE
retail ngto building construction, and hereby authorbo representatives of this
city to enter upon the above-mentioned property fee Inspection purposes.
(We) Agree to sass:, indemnify an d keep harmless the City of Cupertino
g
9 GD
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ALTERORADDTOMFCH.
Datc ReceiptN
SUBTOTAL:
against llabiWics, pdgments, mstsand expenses which may In any way accrue
against said City in consequence of the granting of this permit.
l:,n1F1t1,+'�,Aq 1
AIR HANDLING UNT 17010,000 CFM)
AIRFIANDLINGUNR(OVFRI0,000CFM)
CONSTRUCTION TAX
�—
Si nature ofA Ilcant/Contractor to
B
EXHAUST HOOD(W/DUCT)
CQ-- T CTION PAX
JA
NAlARDOUS ATERIALS DISCLOSURE
/ Y
oj�
BEATING UNIT (PO 100,0)0 BM
Will the appbumee Poture bullding oavpant strum or handle M1uamdous
nmed.l as defined by the Cupertino Mmadpal Cod, Chapter 9.I2, and the
Date Reoei tii
HEATING UNIT (OVER 100,00) EEM
TOTAL'
flexhh and Ssfoy Code Section 2S532b)?
F -1 Y. MN.
VENTILATION FAN (SINGLE RESLD)
I$$ ANF DATE
Will the applicant or future building occupant use equipment or devices
which emit lumardous air mntamlmnts a defined by the Bay Area Air
Rpy1�l
BOILFR-COMP OHPOR 100,0(0 BTU) '
Quality Management District?
Ye, ❑❑ No
have read me har.'allou, materials requirements under Chapter 6.95 of
_4"
CCc 1 41991
BOILER OMP(OVER 1N,000 BTU)
the California Health & Safety Cod, Sectors, 25505, 25533 and 25534. 1
understand that lithe building dons not currently have a tenant, that it is my
,T'L�
r
NEW RESIDENTIAL MECH. SQ.IT.
responsibility to notify the uoupant of the requirements which moat be rest^DM
prior to Issua nm of a Certificate of Ocmpa nry.
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As' fell s
C
1\
ISSUED BY: —
Owner or out eeiment Date
d ag
TOTAL:
OFFICE COPY