20228 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification .PERMITNO.
it nge -1 20228 AnV
ra ost:
APPLICA IION SUBMITTAL DA 11
/t_^ 4-�L, / �- one:
2 C
2Ir #& CITY OF CUPERTINO-BUILDING DIVISION
. ""'°°' Name: Lie.N. ' APPLICATION I PERMIT J l
2114. W Z BUILDINGELE MCALPLUM07NG-MECIIAMCAL CATEGORY CONTROL N
rchltect/Englover 0 Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Acidree ,2)c ,r ' �`SI/ PERMITISSUANCE Y-� ❑ El ❑,
LICENSED CONTRACTOR'S DECURATION
I hereby aff4mt7ut l amlkensed under provislonso(Chapter9(mmmenc APPLIANCES RESMENfIAL .JOB DESCRIPTION
ingwlth SeWon7000)of Dlviem3ofthe Buslnemand ProfeWmsCode,and tryY
license is In haB,torte defect. �t•� PANELS
Llmnsocle, •' LIc.N�_ /ir LJ
Date O Conbractor
ARCHITECT'S —UP TO 2DOAMN
AACNITECTSDECURA N OVER00 AMPS
q�+0O Zp lundentand my pica e)aB be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/$.FT.
k Licensed Professional SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/M
7 t., owing agm.e3eaton 7031mpt(roes he sad Proldor'sLkeae Lw fort he
oo
following reason.(Section 70115,Business and Profeesione Code:Any city ar
Oyj. TEMIs.M ORIOLE T.
r„� countywhlchpe taitebmavesa ttomatuct,alter,quimtheaprove,deos ch,orrepalr
a anya Signe i statement that he la lice sed pursuant t the provisions
of t e IbWFR DEVICES
V (Ile•egnetl statement that he k IlmneM pursuant to the prbWioa of the
Oql- Contractors License Law(Chipler9(mmmencing with Section 7000)o(Divi-
ti�+Oslon3otthe Buslnesand Pro(emba Cade)orthat hekexempt therefromand NC POOL EL CT / t/ V�UATION
<O '
p the basis for the alleged exemption. Any violation of Section 70315 by any OUTLE TCF FI \ Q
applicant for a permit subjects the applicant to a civil penalty of net more than ✓
flue 1,as
dolkrshepro NEW RE51 A E STORIES TYPECONSItUCTION
�n ❑Las owner of the property,or my employes with wages r there sok
m1 p&c.70KO8ldotMworkandtbmCd,:Thurc is nCllnlended o?orcense L v /
Pn mlc(Sec.7014,Busmen and Profemba Code:TM Contradote License law
R$ does not apply loan owner of property who buildsor Improves thereon,and OCC.GROIIP RFS.KNITS
EEEE whodon auchwo,khtorelforthmugh hleown employing,provided that such
Improvements are not Intended motioned forsale.If,however,thebuildingor TOTAL: _
Improvement Issold within one yearofcompldiok the owner-bullderwlll have
tlW.kurden of proving the he did na build or improve for purpose of sale.). QTy, GP MT FEE FLOODZONE APN
L f L as owner of the property,am exclusively cmi .I.g with liaenetd AN
contractors to com ud the project(Sec 7D44,Business and Professions Code:
The Contractor's License Law dm net apply to an owner of property who
IeWs or Improve thereon, and who menet for such pt,ojeds with a AL DRAIN&VENT-WATER(EA)
c7V.dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L_J I am exempt under Sec. g&P C for this reawn BA W PROTECT.DEVICE
OUTSITIF FEES
Oil FLOOR RODF,AREA,COND. SANITARY Y N Owner -Date RECEIPT M
WORK MAN COMPENSATION DECORATION FEKTURES PER TRAP SCHOOL TAX Y N
C31 hereby affirm that I have a certl(lete of consent to seB-loam,ora RECEIPT N
mnlficete of Workers'Comperingtoon/Insurance ma certified copy thereof(Sec. GAS EA.SYSTEM-1 INGd OUTLETS PARK FEE Y N
P00yLpb RECEBTN
Cm anv (( GAS.EA.SYSITM-0VER 4 LFA) BUILDING DIVISION FEES
o
❑CeAiBM copy re(Ikd'Mlh thecityty inspemon division.MClfled cupykherebyturnlsh .' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200H7. Date Remi tR
(7issectlon need not tr completed lithe permit b for one hundred dollars
(SIOD)mlem.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y_ N_
I performance that In the perfounof thework for which this permit b Issued,
I shall not employ any person in any manner n as to become subject to the WATERSYS EM/•TREATING
Workers Compensation Laws of California. Date PAID
OZ Applicant NEWRESIDENTIALPLMB. SQF. Date Recel of
Z D NOTICE TO APPLICANT.If,after taking this Certificate of Exemption,you
should become subject to the Wed..'Composite ion provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this pemrat shall be (2
00 5 deemed revoked. BUILDING e
CONSTRUCTION LENDING AGENCY SEISMIC FEE J
d '0 IherebyafBrm that there k m
a nsrutlion lending ageney for the perform ELECTRIC FEE
mZ aniwork for which(bre perMtkksutd(Bee.3097,Civ.C.)
TOTAL:
LL O Iondner's Nof the Name PLUMBING FEE
LL U Lender's Adaren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imet.1 hel agree to read crnply lith aBmtbaand staty retinaatthe above dgateelon
1 remind.lagrre to complywlth all ndharbyauntyordinancentat gate lam PERMITISSUANCE FEES PAID.
r fA relating to building construction,and hereby authorize rcprnentativn o(thk
F city to enterupon the above,mentioned property for Inspection purpose. ALTER OR ADD TO MUCH.
? (We)agree to use,fedemey an d keep harmless the City of Cu ped Ino Date ReceI t41 -
V a ainet liabMiles,jadgments,ansandexpensewhichmaylnanywayanue AIRIIANDLINGUNTT,7010,000CF14) SUBTOTAL:
g at sed Ciln m scq enm mf the granting of thta permit.
aAAk� AIR HANDLING UNIT(OVER lo,000cFM) CONSTRUCTION TAX
' CONSTRUCTION TAX PAID:
Si re al ApplHAZA rounder Date FXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Wfll tsI as definanted
theur ionizebuildinggoavpan ode,storhapten 9.h,ant xishe TIDYING UMT(TO 103,000BN) Date Recti tq
Health
as daBnyd by the Cupertino Municipal Code,Chapter 9.12,and rice -
FkalthandSafety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea f]No
Willthemit haranousair contamildingnants
occupantshred se equby
IpmBay Area devices VENTILATION PAN(SINGLE RFSID) I$ DATE
which emit haerned airrict! antaasdefined 6y the Bay Area Are
. Quality Maagemenl Dretrin7 BOILER-COMP OUP DA 100,000 BTU)
F�IYe 9No MAY U1 1�u
`)'have read the bazar ousmeedatsmquimwntsunderChapter&95of BOILER-COMP(OVER 100,000 BTU)
the Callfomia Heelh&SafetyCode,Sedlons 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It re my NEW RESIDENTIAL MECH. SQ.FT. /� .a
responslbilltytonoli the occupant of the requirements which most be mot CIt}r DI r.nlp'41f10
r to issuance of rtl tc ofOavpanry.
Ow rorauthorimdagent Date ISSUEDBY: �" V
TOTAL:
OFFICE COPY'