21425 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
-
Building Project Identification PERMIT,NO.
Building 21425
wrI are: one: • - _ APPLICATION.
0.l 3^ CITY OF CUPERTINOLBUILDING DIVISION
rLie.•
a o'.Nx +. a: - APPLICATION / PERMIT
n BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORYCONTROLp
Architect/Engineer. 'Lie.Nu
'QTY 'ELECTRICPERMFL 'FEE BUILDING PERMIT INFO
Address: A R� PERMRTISSUANCE ❑ EJ El., �)
LICENSED CONTRACTOR'S DECLARATION - L El'
I hereby
affirm tlutlam licensed underprovlsione of Chapter9(commmo- APPIlANCESRE57DENTfAL JOB LIF—RETMON
Ingwith Secdon7000)of Diviaion3ofthe Businessandd,,PProfesslonsCode•and my 11
p
license la in fu rifest. PANELS
L Clam L in --+
Dat Contractor
ARCHITECT'S DECLARATION MI-1000 AMPS
Ore 2 I understand my plana shall be used as public records. OVER]ODD AMPS J SQ,FC.FLOOR AREA E/SQ.FT.
25i .. Licensed Profewlorul - SIGNS ELECTRICAL i
GG OWNER•BNLDER DECLARATION SPECIALCIRCUIT/MLSC
p., I herebyafRrmthat I am exempt from the Contractor's License Law(oaths
following reason,(Section 70113,Business and Professions Cade:Any cityor
OO u9er, o TEMP.METTRORPOL ST. e t
eUj mystywhkh rrquireaepertNtto al..re thestistipmvamforsch,ermit to ,
anyatvdure prinew statement
that he I.Wensed restheapp0unt(or each permit to 1'
file a signed Ratement that he la licenced pursuantIbWER DEVICES to the provisions of the -
Contractors License Lau,(Chapter 9(commencing with Section 7DOO)ofDivi.
1..,30 Mon3 of the Business and Professions Code)orthat he is exempt therefromand SWIMMING gECTRIC f '� P VALUATION
the basis for the alleged'exemption. Any violation of Section 7031.5 by,any L' ro f( • _
<
applicant fora permit subjectathe applicant to a civil penalty ofnot more than OU3L1S 7'CFEESI ES,,
five hundred dollars($00). •1( t +
g I,as owner of the roe NEW R ENTIAL ELEC f4 ZA. STORIES TYPE CONSTRUCTION
p^�n ❑ property,rty,or my employees with wages offered
sok -+`
compensation,&c.tion,Businessl do and
rk,Pr and the Professional
ode:e Is The as Contractors
or License
Law A
D sale(Sec.apply
to Business and f property
Code:The or improve, hemor,Law -
� $' does noes such torn owner otpropertywho Wllds mporlmproovidedreoryand - OCC GROUP RFS'UNITS
F
who doeesuchwork himseBarthrough Nsownemployees,provided that such
Improvements are not intended xioffered foAale.If,however,thebullding or W IPOTAL:
Improvement lasold withinoneyearofcomplHbn,the owner-bullderwill have
it)9kutenofprovingthat hedid not build or Improve for purpose ofsakJ. QTY. P GING PERMIT FEE FLOODTDNE. - APN
t Las owner of the property,am exclusively contracting with licensed PERMIT ONCE
contractors to construct the project(Sec.7094,Business and Profmcdom Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FN t '
Wilda or improves thereon,and who contracts for such ptojeata with a
mit acroKe)Rmneed pursuant to the Contvnora Licenx Law. - I FEE SUMMARY -
LI I am exempt under Sec. B&P C for this reawn BACK FLOW PROTECT.DRVICE
OUTSIDE FEES
OwnerDate - DRAINS.FLOOR,ROOF,AREA,COND. SANEEARY Y N
-
WORKMAN COMPENSATION DECLARATION RECEIPT X�.���.�a SCHOOL TAX Y N
(�I hereby affirm that 1 have o lasura te'of consent to opy thwre,ora 1A. RECEIPT X
tea(Workere'Compensatlonl�7rmu�ranm or/a�ceklfkd ropythereof(Sec. GAS F.A.SYSITM-]INC40UTLETS PARK FEE Y.- N
Po00,Lab CJ"Y .�6-�L')-V _ DINGRFJCEIPf
DIVISION
Policy V GAS EA.SYSTEM-OVER<(FA)
Com any y�pY '(lE1y�(i -' BUILDING OI VISION FEES '
• [PCemned copy la h .by famished. GREASE/INDUSCRL WA53E EPTOR - PLANCHECK FEE
- ertifled copy is filed with the city inspection division. - .j
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
PAID-. -
COMPENSATION INSURANCE SEWER-SANRARY AM EA 2fI0F1' Date ReCel •t#
(Chia section need not be completed If thepermit bforom hundred dollare
(S1W)or leas.)- Of
WATER I-IEATFIt /VENC/ELECTA - ENERGY FEE Y N
I certify that In the performance of the work forwhichthid permit is issued, '
I shall not employ any person In any manner so as to become subject to the WATER gY /TREATING i
Workers'Compencation Laws of California.Date 'PAID -
O Z AppliNOTICE
NEW REST -LPLMB. SQFC. Date Recei ht
nt
Z Q NOTICE co APPLICANT:a after Work
ermaking s'
a sationlpro is Exemption,you
Code,shoulyou
mus forth it the Workers'such I uatlo m orchis permitns,of s Labbe - TOTAL:.^
N denoted
must forthwith comply with such provtilora orchis permit shall be '1 BUILDING FEE
9 deemed revoked. � � '
d -CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there is a construction lending agency forthe perform- ELECTRIC FEE
Z anceofthework forwhichthis permit is Issued(Sec.3097,Clv.C.) TOTAL:
(� O Lender's Name ' ' PLUMBING FEE - - '
LL F, Lenders Address QTY, MECHANICAL PERMIT FEE . MECHANICAL FEE t
OW ,Imrtlfythatl have readthisappliratlonand rtatethatthcabovelnforrration
C Is correct.I agreeto complywith all cityand countyordinances and nate laws r PERMTTISSUANCE FEE$PAID:
} relating It, ding corutructlon,and hereby authorize repremntativee o(thla
H U)
cit se
u on theaWve-mentioned property for inspection purposes. ALTER OR ADD TO MECH. -
(We) ce o cave,Indemnify an d keep harmless the City of Cupertino Dale ReCe1Pt#
V agx'12 bilis judgmenre,caste and expenssawhich mayina ywayaeane AIR HANDLING[MI'I CTO 10,000 CFM), SUBTOTAL:
agalrute IdC 1 c n e lilac granting of this pe ( -
—'I�Yfi�l AIR HANDLING UNIT(oven lD,DDa cFM) CONSTRUCTION TAX
Signature of AppBrant/Contractor EXFIAUS"CHOOD(W/DUCT) _ CONSTRUCTION TAX PAID: '
HAZARDOUS MATERIALS DISCLOSURE '
Willtheappllcent or future Wilding occupant store or handle hazardous HEATING UNIT(TO 100,m0 BTU) .
"material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - p� Date Recei t#
Health and Safety Cod arr�Section 25532(a)7 ' HEATING UNIT(OVER 100,000 BTU) IrVV TOTAL: ��
❑Yes I__I No'
Wlllthe applicant or Towns,Wilding part use equipment ordevices VWnLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? .� BOILER-COMP PHP OR 100,DMRTU) '
[?have Yet �No A I 1
rtheth& ossa Code,materialsSectioulrerrenhunder Chapter.1 of BOILER-COMP(OVQt 100,fA10 BTU) rtf'frr.�, J
the Californianla Health&Safety Code,SMloru 25505,'25533 and 25534.I - 9�'a
understand.that If the building does not currently have a tenant,that itlamy NEW RESIDENTIALMECH. PEC EC - 4, 1990
responsibility to notify the occupant of the requirements which must be met _t7�/ _
prior to issuance of a Certiflcate of Occupancy. _ •• pA" + .,
{ —4GLLV cur^ar��ItlX.y'r1.q��: a'
Owner or authorized agent - - Date ISSUED BY:
TOTAL:
OFFICE COPY