21250 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Build Ing Project ldaNlflnllOn PERMIT
Building Address:
a^ ^ ��O l � S 21250
wners a i• L one. _
CITY OF CUPERTIINO-BUILDING DIVISION n
c lractw' ams:
Lic.Nee APPLICATION I PERMIT I C9 3-40 .
CC Vkl,.kJ *TaCIL BUILDING-M PCTRICAI MUMBINGMECHANICAL CA'ITfARV CONTROL N
Architect/Engineer. Lia No:
FWD •�¢StioBUILDING PERMIT INFO
'c --I" Itt5 QTY ELECTRIC PERMIT FEE
Address:. 29bCo o`13 -• PERNRTISSUANCE .. - ❑ EJ
DECLARATION
Il hereby affirm that l am licensed under provedoes of Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL JOBD HIPHON
Ingwnisin1on700aandeffea, ofthe Buslrlmand PminslonsC.ode,and my - - c `
licensebin(uB o-I and cN s__ PANELS
Llrena��C�ah�m''tt,,� Lica �-
Date_�_at_ Contractor UP TO M AMPq
ARCHITEC'SD CLARATION 201-10D)AMPS
q�+x C70, lundentandmyplawshallbeusedupubhcrecords OVER1000AMPS' SQ.FT.FLOOR AREA 5/SQ.FT.
i4 d(/ Limnxd Professional SIGNS EIFG C L
< OWI am exempt LDER
DECLARATION SPECIALC@C T/ HSC
io„ 'I hereby affirm that Lem ezemplfromthe Contractor's License Law for the
ZO 2- following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.Mi., OR IN
FE cxuntywhich requires a permitto mostred,alter,improve,demolbh,oreepalr
q' anyatmcture prior to lie Wuance,alao rcqulrestheappllant farauch permlit. POWER'D
E9 fair a signed rtatement that he is licensed pursuant to the Pro In.of the
30� Contractors License Law(Chapter9(mmmenringwlth Section Mahar(Dlvl- gW1MAgN L
alon3o(lhe Buelnmand Profmiom Code)orthathebexam thercfromanduAh4 VALUATION
Q Q S the bask for the alleged exemption. Any violation of Section by.any 011rL ESQy'BOG. cid
was appOcantfor a permit subjects the applicant to a civil penalty of natmom Hun
five hundred dollars(5500). SQFT. STOIRIFS TYPE CONSTRUCT ION
�n ❑I,as owner of the property,or my employees with wages as their sole ID• ELEC i
C compensation,will do the work,and the structure is not intended or 0actedfor ,
5 ask(Sec.70K Business and Prufealmn Code:The Contractors License law
1 5$ docs not apply to an owner of property,who builds or lmprems thermn,and OCC.GROUP RES.UNITS0.0. who does such work himelf or through hleown employees,provided that sock
improvements are nDt intended proffered forsale.lf,however,thebuilding orTOTAL: '
Improvement ksold wilhinoneyearofcompIMlb themner•builderwill have
tliL�urden of proving that he did not build or improve for purpose of sale.). QTY,"PLUMM41NG IT . FEE FLOOD ZONE : APN
u L as owner of the property,am exclusively contracting with heirsed PERMIT ISSUANCE .
mntracton to construct the.preject(Sec.70K Business and professions Code:
The Contractor's License Law does no apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
builds or improveora s
s thereon, and who contracts fur such pKeJecwith a
Off,ctor(a)licensed pursuant to the Contractors Llmose Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY'
LJ I am exempt under Sec. B k P C for thin reconQUTSIDEFErS
SANITARY Y N
Owner Date DRAINS W.DOR,ROOF, COND. RECEITN
WOR KMAN COMPENSATION DECLARATION FIXTIIRFS PER TRAP _ SCIgOOL TAX Y N
❑f hereby affirm that I have a certificate of consent to self-insure,ora RECmxF M
cedltlab xf Wprken'Cxmperwrionlrsuranreoracertl(ked copythereo((Bec. GAS F.A.SYSTEM-1 INCA OUrLEFS - PARK PER Y N
3800,UbC.)
Q policy#_–)t�BZ5 �q0 GAS PA.SYSTEM-OVER4(EA) RECETTN
Com inv_$tsNSRE'_ 'F1w.vJrt� BUILDING DIVISION FEES
0 Certifid copy b hereby(umbhed. GRPASE/INDUSIRLWASFEINTERCEPTOR PLANCHECICFEE
❑Certi(Ied copy b/ikd with the city inspection division. '
I
CERTIFICATEOFE%EMITION FROM WORKERS- GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTFARYSIURM EA 200FT Date Recei tM .
Rhieuctlon need net becompleid If the perrtdt b for cave hundred dollen
' ($10(fimlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mr[ify that in the performance of thework forwhich this permit 1.is —
I shall not employ any perms In any mariner m as to become object to the '
Workers Compensation Laws Of GII(Ornitl. DWATER SYSTGt/TREATING
ate PAID
Z Z AppilNOTI E NEW RESIDENTIAL PLMB. SQFF. Date Recoi tit
Z Q NOTICE TO APPLICANT;H,aker making this Certificate.(Eaamptimt,you
Fshould become subject to the Workan'COmpeneation provisions of the Labor TOTAL:
W Code,you russet forthwith comply with such provisions orthb permit shall be
j deerooked. BUI Ob so
''E I
a —p CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby affirm that there Ls a construction lending agency for the perform ELECTRIC FEE
Z anco of the work for which thin permit is Issued(Sec.3097,Civ.C.) TOTAL:
O O Lenders Mi. PLUMBING FEE
LL F• Lend.ea Addrc,a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (27
O W I coolly that l have readthbapplkationand nate thalthcabove Information x
C bommet.Iagreetx cxmpiywilhalldtyand muntyoNlnanmand state laws PERMITLSSUANCE FEES PAID: .
relating to building constroctlon,and hereby authorize representatives of this
FZ ' city to enter upon the above-mentioned pmperty fou inspection purposes. ALTERORADDTDMECH.
(We) Areave,indemnifyand keep harmless the City of Cupertino - Date Recei tic
V against abllit a dgmenro,conarid expenses which cosy inanywayamme AIRHANDLING UNIT(TO 10,ODOCFM) SUBTOTAL:
again aid I inconsequence !#granting of this permit.
CO-3—ru AIR HANDLIN°UNIT(OVER 10,W0 GEM) CONSTRUCTION TAX
Signefdonof Applicant/Contranor Data E(HALSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheapplionI or future building occupant scum or handle harardous HEATING UNIT @71DD,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I With and Safely Code Sectlou 2553200? HGTING UMT(OVER 100,000 BTU) TOTAL:
❑Yes �4 No
Will the applicant or futu m build Ing occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE .
which emit haaardous air contaminants as defined by the Bay Area Air
Quality Management Dy�t o? MOILER-COMP 01 Rs OR 100,000 BTU)
110
Q Yes IJI No
Thave read the Faze pus materials requirements underChapler 6.95 of, BOILER-COMP(OVER 100,00)BTU)
the CaliforniaHealth&Safety Code,Sections 25505,25533 and 25534. I J �'+'�✓a���E{
��ts 4 VI
senders n that if lhebuildl oes not currently have a tenant,that It b my NEWRESIDFNTIALMECH, SQ.F-E Q1±!'�
mspo ib tyto nptl(ylheo m ant of the requirements which must be met r R
pr' o seance of,Certi at fOcmpancy. " I �V ti\ ZedD
!0-3-50 }ltilCc� xt:�
ser or autho sed agent Date IOTA ISSUED BY
I /.:
OFFICE COPY