23010 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proe dantlfication PFR.MITNO.
Building Add , 23010
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w e phone: p p
P 1 CITY OF CUPERTINO-BUILDING DIVISION p
Conlndor's Name: uo.No: APPLICATION / PERMIT
BUILDIN0.ELFG'IRICALnL BING-MF MCAL CALF-GORY CONTROLM-
-� Archite Lie.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
"�l PLUMS
Address: PERMITISSUANCE El El ElLICF.NS.D CONTRA OR'S DECLARATION
Ihereby affirm that l am licensed under provision,of Chapter9(mmmme- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Section7000)of Divlslon3 ofthe Bud remand ProfeadonsCode,and my ,
license 13
In full to.end died. PANELS
at Clan LLC
DM
Date Cic. r UP 102011AMPS
ARCHITECTS DECLARATION MI-1000 AMPS
q 7 I understand my plans shalt b,used as public remeds OVERIOWAMPS SQ.FT.FLOOR AR 5/9Q.FT.
O
)ti d 6 Licensed Pe feesloreal SIGNS ELECTRICAL / E
EN OWNER.BUILDER DECLARATION SPECIALCIiCUIT/MISC
F' 4 Ihembya(Rrmthatiam axemptfromthe Cant raaors Llanse Law(or the —PUT
g L�
79 q�( following resson.(Setion 70)15,Business and Profenions Code:Any city or \ p p y fr R
FJF,3 eepair TEMP.METER ORPOLEIN 'v u l'�
EQ cauntractumy which rcqubesa perMttoroorequiresthemprovgt forsuah,ormitto
s mm any.signed prior its he Is licensed
pursuant
t the provisions
of [ e ppkyEg DEVICES 3
O r4 file a signed statement that he 0 licensed(commencing
it the tion 70M)
of the '
ContractoreBusinseGw rofesslonsCChapter 9 om)orthagwithSempttheWfermanl- SWIMMING OGLE EC AC DA
O sion3o(lhc Business and Pro(calons Code)orthat hole,seem thercfromand VA TIO
1 Y.' the basis for the alleged exemption. Any violation of Section 7MI5 by any OUTLEISSWITCHESFIXTURFSaUV c /1 f
'
Pd<5 applicant furs permit subjenatheapplicanttoa civil penalty anal morethan
G y O five hundred dollars($500).
,$ NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPECONSTRUCTION
.- ❑I,as owner of the property,or he employees with wage r their sole
C7<,
compensation Business and kandthes Code
Th net
commm'o License
eLaw O
ya D sale(Sec.apply
to Business and f property who
Code:The or impaws License Law ..
don notapply loan owner of1proughhis onemorimprovnthereon,thatand such OCC.GROUP RFS.UNITS
C0..
who dogs wch am nothimselfdeck through his ow formic.
If.employers,providde uilding or
improvement imold inti,dedorrofco plc io.t however,e. Hderwili have T T�.: 1
i provementbwld whhinoneyeamfcomplelion,theowner-bullderwillhave
th °rdcn of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
I,as owner of the property,am excluslvely contracting with Ilcensed pFRMIT ISSUANCE
contractors to roretruct the project(Sec.7014 Business and Yrofeashms Code:
IC
The Cont ,tars License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves themer,and who contracts fee such piojem with a
" Iactw(s)licensed pursuant to the Contnctots License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
-
DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECKIPT It
WORKMAN COMPENSATION DECLARATION ,
01 hereby affirm thce
at I have a rti0ate of consent to self-inure,or pyyTUftEq PER TRAP SCIiOOL TA% Y_ N_
u ,
et RECEIPT X
certfic,en ofW.,lmrs Compgnmti.oImunmcce ora certified ropythemof(Sec. GAS EA SYSTEM-1 INC4 OUTLETS PARK FEE Y N
Mal lab CJ RECEIPT M
Cony ohry M CAS'EA.SYSTEM-OVER 4(EA) BUILDING DIV]SION FEES
Ca '
ECeriieed copy is hereby furnished. - PLANCIIECK PEE
Certified copy is filed with the city impecti°n division. CRFASE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTEARY-STORM EA 200FT atC RCCCI t#
(This section need not be completed lithe permit is for one hundred dollars
W00orles,.) WATER IIFATEt w/VEM/ELGCTR EN' Y.FEE Y_ N_ .
I cortilythat In the perfornunceof the work forwhlch this permit Is Issued,
I shall not employ any person In any mariner an as to become subject to the
Workers Compensation Lawsof California.Date WATER SYSTEM/TREATINGP D
'
O Z Applicant o NEWRESIDPNTIALPLMB. SQ FT. Date Reed t#
Z O NOTICE TO APPLICANT.If,a fter making this Certilate,of Exemption,you
Fshould beenere subject to the Worken'compensation provisions of the Labor I TOTAL:CC ,Q
N Cade,you must forthwith comply with such provisions or this permit shall be (, \ �
W > daemedrevrAed. BUI LNG F' • ,
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercby affirm that them baconstruction lending agency for the perform ELECTRIC FEE
7 Z ansaofthe workfor which this permit b Lbeued(S..3097,CIN.C.) t—` I
02 Lender'.Name PLUMBING FL•E � ^LLF Lender',Address QTY. MECHANICAL PERMIT FEE MECHANICAL PEE ' 1
O W 1cedlfy than havemadthle applicatlonand datethattheabove information �..,
is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE Il FEES PAID:
} N relating to building construction,and hereby awhorira representatives ofthis
city to enter upon the above-mentioned property for impMlon Purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harmlem the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may In anywayaceue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
against old City in ron,ryuence of the grating of this permit AIR HANDLING UNIT(OVER 10,000CrM) CONSTRUCFIONTAX
Signature of Applicant/Contractor" Date AI)STHUC
OOD(W/DT) N3RU TION N
D(H
HAZARDOUS MATERIALS DISCLOSURE rzTO / -_�q—
Willtheappllcntcefdare building oocnpant store or handle hardous HEATING UNIT C 100,000 BTU) Date Reed t#
material a,defined by the Cupertino Municipal Code,Chapter 9.17,and the
I and Safety Code Section 75532(a)7 ' HEATING UNIT(OVER 100,000 BTU)) TOT L:
Will
,�No HA
Wlllthe]% pWtoe tum building as defined
ndby the BayequipmentArea devices VENTILATIONPAN(SINGLE REBID) I$$IJ�ANI DATE
which CMI hagements air contaminants an defined by the Bay Area Air -
Quality Management District? ROLLER-COMP pI-0'DR IW,IXq BTU)
1 ve Vo"° JUN 12 1992
have read the bass oils materials mqulmments under Chapter 6.95 of BOILER-COMP(OVQt100,000 B1U)
the California health k SafetyCode,Sections 75505,75533 and 75534. I
understand that lithe building docs not currently have a tenant,that It u my NEWRESIDENTIALMECH. SQ.FT. /s I;I)( UY `/VEEit 1
iisv
nsponsibs ane of a Ceheompantof panty.ircmants which moat be met .. V
prior to issuance o!a Certificate of Occupanry. O l
Owner or aulhodre,iagent Date ISSUED BY:
r�
OFFICE COPY