21874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuWing Add
Building R.M
Proect ldentlfkation PETT NO.
21874
DCITY OF CUPERTINO-BUILDING DNISION
vamme° .Zr.� ( '�
e .Na — No. APPLICATION / `a
PERMIT
RNLDINGELH:"IRIGV�PLIIMBINGMECHANfCA1, CATEGORY CONTROL,1
Bea/Engfrcer. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add revc �r5 PFRh4TISSUANCE PLUMB MELH
O ❑
LICENSED CONTRACTORS DECLA ATION
I hereby affirm thatlam Bcrosd order rovWon.ofOupter9(�nmm AITLIANCFSRFSIDEM7AL J BD6CRR'IION
mgwith Section70MmDtvldon3o tImB andlmetalcmCode,andmy
11¢nxbin(calif and cites.
Limn s Lk s
Da Co or
ARC ON MI-1000AMIS
AGOG Iandttwnd my pbashailhe calci publicreaada OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
obU Licensed Professional SIGNSE,ECTRICAL
6 OWNER-BUILDER DECIARATION SPECIALCDICUIT/h1LSC
IherebyafBrm that lam exempt from the Contractor's License Law for the
p following reason.6ection 700315,Buslnmand Profeaona Code Any city or
TEMP.MEM OR POLE INST.
K� county which rtcrylmapemdtromoavuct,iltrr,Impmve,demoWh,orrepalr
nayatmcture prior to lrolauarce,also reteirestheapplicant for such permit to POWER DEVLCFS
U file a signed statement the,he Is licensed pursuant to the ImMsbm of the
Qt, Contraaorb License Law(Chapter9(cemmenangwBhSectbn7DOO)ofDio-
SO cion 3 ofthe Bu nn.and PrdmIons Code)or that he b exempt therefrom.rad SVDdMWG POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any dalatbn of Section 7m I5 by any I
SOAappbmntfora permit wbjcma the applicant to a civil pens Ry of not more than OUTLEISSW[TCHESFUCNRFS M�
�c R�,SS.�W, .dreddd1,m%M L CJ•�
raz�n 2.11,a owner of the property,or my employees with wages a their sole NEW RESIDENTIAL ELFLIR 9Q 'STORIES TYPE CONSIRUCIION
�4compensation,will do the k,..d the structure is not Wended or offeredfor I
OO .1e(Se,70K Bu,B and Pmfesbv Code:The Contractors Llceme Law
i1d $ does not•pply to an owner d property who builds or improve,therms and
UN7I5 OCG GROI/la RF5.
CC who doeswch work himself or through his wsuchown employees,prkled that
improvementsaremtmtendedoroffe dfmale.If,however,theWildingor TDT
ImprovementbwMwlthnomyearofmnpleb ,the¢vner-bullderwihave
LhLJ?uraenofprwingthathedM rctb fldorlmpnwefmpurpo'eofale.). QTY. PLUMBING PERMIT FEE ELOODZONE APN
LJ L a owner of the property,am exclusively mntractlng with licensed
mntractms to matma the project(Sm 7Dly Builnm and Prdmba Cad, PERMIT ISSUANCE
The Contractor's License law don not apply to an owner of property who ��DRAW 6 VFM-WATER TA)
or Improve thereon,and who contracts for wch p,psa with a
ry0tT+ctor(.)lmn,ed p...nt to the Cembaaor.Lina Law. Bwac FLOW PRarerr.DEVICE FEE SUMMARY
IJ I int exempt uMtt Sec B 4 P C for this renin
DR INS FLOOR ROOF,AREA,CONT). SANITARY Y_ N
Owner Dns RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SQiOOL TAX Y N_
❑1 hereby dfbm the,I have a¢rHllate of coram to self-loom,ora RIX:m'I.Y
certlBcate of Worken'Cwnperuauon lnwrancema¢rtBkd mpythereaft5ee GAS FA SYSI.FM-I INCA OUTLETS
38PARK FFR Y_ N
s 0,Tab CJ
Co GAS IA.SYSTEM-0VER Y(TAI RLCEPT Y
BUILDING DIVISION F
Y EES
CertlRed copy Is hereby h rnbhed.
E led copy Is filed with the city iapectbn dlvbfon. CREASE/WDIUSIRL WASTE INI"ERCEPTOR PLANCHECK FEE
CERTIRCATE OF EXFM PTION FROM WORKERS GRIaSE TRAI• PAID
COMPENSATIONINSURANCEt1RANCE SEWER- STORM EA 700FT Date Remi t#
(I'weeebn need not he cmnplaN B the pemit b(more hundred dollars
est 00)wlm3 WATER HFATERw/VFNTT/Elri ENERGYFEE Y N
I¢rtBy that in th dormnce of tM1e work for wMchtw permit Is issued,
I shall na empb a n In ay nun e a become b to the WATER SYSTEM/TRFATING PAID
Warken rias T6wi Womb ,e j=b!�
O Z APP t
2 O N tt=RgtwCertlf mofEumptbn, you NEWRES'DENTIALPLMB. SQ.FI'. Da[e Remi t#
shm rnew tothe Warken'Compenatbnprwbbesofthelabor TOTAL:
WCCN Code,yourruatfret with oanply Mth wch proWba ortw pemaB shill be BUILDING L
> domed revoked. FEE
CL c CONSTRUCTION LENDING AGENCY SEISM19 FEE t
I hen:by afflnn that the¢b a construction lerding agency for the perform
7 Z arm of the workfor which thbpermn b bsuod(See.30 Y/,Civ.C.) TOTAL ELECTRIC FEE
U 0 Lender's Name PLUMBING FEE
LL F lender's Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdifythmlhevc rtadlM1bapplkatbna�d Wtethxthcabovcinfonrutlan
bmrme.Iagrm to comply wnhWdtyand munryordlnanmand state law, PERMIT ISSUANCE FEES PAID:
>_ a misting to building matructlon,and hereby'uthorlae representatives of this
F. Z ety,to enter upon the abovt mentbrcd property,for Inspection pu rpos-s. ALTER OR ADD TO MTLH, Dale Recei t#
— (We)agree to save,Bdmm
emrdfy an d keep haithe City of Cupertlw P
agaWt BabiRtlee,pcigmew,cuaaand expenan which may In any wayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.9.1at sild City In mnas,equenof the granting of W.pemit
AIR HANDLING UNIT(OVER I0,0)O CFR() CONSTRUCTION TAX
Signature of Applicant/Commefor Date ]DULAUSTflOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuwn,building o pant store or handle h—mims HFATWG UNIT(TO 100,000 RTTI) - Date Recti t#
material.,defined by the Cupertino Municipal Code,Chapter 9.17,and the
Heahh and Safety Cxxk,, ion 255n(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
n Yn h(I No
111 the appilcent¢fu—T.re building«cvpaeum equipment ar devims VINIILATION FAN ZWfiQE DATE
which emit hascrdw.ab rwtartirunt,a tle0rcd by the Bay Arta Ab
Quilnyn nagemerB Dbtrkt7 BOILER{OMP O7iP OR]OQO(A Ri(1)
YY Na Fe.
have read the hariils requirements under Clupter 6.95 of ROE.FR-COMP(DVFR 100,000 BTU) 8 G 991
the Ca lBomia Ith A Sdety p Sections 25.505,75533 and 25531. I
undmt. t` tithe building don wrrtnllyhave a tenant,that it b my NFW RESIDENTIAL MECH. SQ.FT.
raponibBity o he occupant nqubemente which at be met /�s1Fs F}'� I •TMS
prb ace to of
lavner or ent - Date
TOTAL ISSUED BY: K.1LY.r
OFFICE COPY
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