21484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Bu hog Address: '214 8 4
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{aA1C� h�fl N�Q r I f/U one: APPLICA11ONSUBMIIIA1=A -
CITY OF CUPERTTNO-BUILDING DIVISION �n _ CW In
C(�ot(r/a�aora N ma: Llc. o: APPLICATION / PERMIT r Cf
o - catij r4 BULDINGELECTRICALPLUMBINCNfMHANICAL CA RY CON1tOLN
ArchICM ner. LlcNo:
01-Y ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
ICF,NSED CONTRACTOR'S DECLARATION
Hanchyafflrm that l am licensed under provisions of Chapter 9(commene- APPLIANCESRESIDENHAL JOB DESCRIPTION
Ingwlth Section 70OO)of Dlvlslon3ofthe Bushdsand ProfessionsCode,and m
Ilnnse le In(uB lggqqssqqpN and erreR. � ^^ PANELS
I. -7Clas+ !S Cont ice!
Date-/�(5-�'�s�ContndorUP TO 200 AMS
ARCHITECTS DECLARATION 201-1000 AMPS
PQ+O`LOCC I understand my plarashall be used as publicrecoWs. OVER IODO AMPS SQ.17.FLOOR AREA $/SQ.ET.
E U Llmrowd Professional AGNS ELDCTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCRCUIT/MLSC
71.., Therebyaffronthat lamexempt fromtAe Contractors License Lawforthe
O following reamn.(Section7011S,Businewand Pre(essiono Code:Any city or
t. TEMP METER ORPOLE INST.
K4 countywhire requlrna permit usuancomvdruM alter,requirsthemprovgdemsuch,ermit to
a any structureprier tent thauanco,licca sed pursuant to
forsuchto POWER DEVICES
V (Ilea actor'd statement that he le Ilwmed pursuant to the len 7000)a( the
3µ Con3ofthee LicBusiness and
rofesser9(mmnnncing eI.exith emptth 7000)of Divi-1 O G SWIMMING POOL ELECTRIC
(he
3os he the alleged
Professions Any alrthathebeection here(mmary }IQLUATION
d <5 the blab for the alleged eecta the n. Any violation o(Sectlon 70315 by any OUTLETSSWITCHESEXIUR
fiveapphundrera d delta.IBM. the applicant tea dull penitydnd mom Rico
a flue I,a.. .r.fthapr. NEW RESIDENTIAL ELECTR
�n ❑Lasion,wof theproperty,or my empbyedwith ended as offered
STOWFS TYPE CONS'IR[X:T'ION'
C
compensation,(St. 044 Badnessl do
work and the si.. ode:Th n Intendedontractor or callers.Ter
5 dale(Sec. pply Rusbiessandf property Code The or Impdofa Licene Law
J 5$ does nonsuch torn owner of trough his onemplrimprwnded th t,and OCC.CROUP RE£UNITS
F. who dodsuchwork hinneaorthreugh hisownemployees,providM thaiduch
Improvements are not Intended muttered(orsale.If,however,thebuilding orTOTAL:
improvement bdold within eneyearofcompletion,the owner-buUderwill have
ttaIjurden of proving that he did not build or Improve for purpose of sale.). QTY, PJ- NG PERMIT FEE FLOOD ZONE APN
L j L as owner of the property,am exclusively mntrading with Monne.
contractors to construct the project(Sm 7044,Business and Profaoloas Code: PERMIT ISSU
The Contractor'.License Law does net apply to an owner of property who �.�-D -WA (EA)
Wilds or Improvn thereon,and who contracts for such plot.with a FEE SUMMARY
egpl(actarW licensed pursuant to the Contractor's License Law. IX TEC . C
I am exempt under Sec. B&P C for,this reason
D N R COND, SANITARY Y_ N_
Owner Date RECEI N
WORKVIANCOMPENSATIONDECLARATION PER
QI hereby Affirm that 1 have a certl0cate of consent to del-Inert,w a SCHOOL TAX Y RECEIPT N
certl0catoofWorkers'CompenalionlmunnreoramrtlfW ropyhereof(See, GAS .SY 1 NC,4 I7ILET5 PARK FEE Y N
3800,lab C.) RECEVF M
I
A
I'eI1cyM
AS.F.A. VER4(FA) BUILDING DIVISION FEES
Com anv_�N{I,y bp1-
Certified ropybllere !uM GREASE/ WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b(Ikd with the sly Idpedbn dlWelon,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE IRb PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA H)OFT Date Recel-t#
(I'hbeectlen need not becompleted If the permit b(wane hundred dollars
U100)orfyth WATER HEATER W/VENT/171 TR ENERGY FEE Y N
I cenot that In the pr'dormnin an theworkmanter(o as to b this permit b Issued,
I.hall not employ any Laws f any rttanner m u to become object le the WATER SYSTEM/TREATING
Workers'Compensation law.o(Callfamla.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB, SQET, Date Recei t#
Z O NOTICETOMPLICANT:IL aNer,making this Certificate of Ezcroption,yen
should become subject to the Workers'Cemperetatlen pmvbied.(the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING
FEE
W 9 deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC ELECTRIC F
I hereby a(Brm'rhat which t i a corutroction lending agency for the perform- ELECTRIC FEE
L) Z Lenderthe work forwhkh this permit Is Issued(Sec.3097,CIv.CJ TOTAL:
LLO Lender's
Iy H L nder'.Name PLUMBING FEE
Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW beret.Itdgmencreadhbappllcitynand dcuntyordihuboveinformation ddatelaws
1 Is correct. buildig comply withaction all ndhereb rouhorim represeandeesoftws I'ERMITISSUANCE FEES PAID -
>. W relating
oenterupon t e bone, en;enedpropftyfrl in representatives of this
city Wenleree to the indemnify an
property less th Cit ofCu es.Cupertino
ALTER OR ADD TO MIGH.
Z (We)deme to eve,Indemnify en d keep harmless the City of Cupertino - ale Receipt#
V
against liabilities,judgments.coesand..Pa..which may in anywayacave AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
agaWtaa Cityin cone enceof the granting of this permit.
iii
Q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgrffiwreo( cot/Conlnctor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building occupant store or handle harzrdous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as deft ned by the Cupertino Municipal Code,Chapter 9.12,and he
Ilealth and SafetyCodlre_-_S,Iection 25532(a)1 HEATING UNIT(OVER 100,000 BTU)
❑ L:
ill he applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINCLF-RESID) ISSUANCE DATE
which emit haaardousaircontamlruntsas defined bythe Bay Area Air Quality ��� ay.lJ D
(�
Management District? BOILER-COMPC1HPOR 100,0(*BTI!) {
Yes ❑No
have read the harurdousmaterias requiremenh underChapter6.95 of BOILER-COMP(OVIR 100,000 BN) '
the CAIllornia health&Safety Code,Sections 25505,25533 and 255M. I N;jda ass fa..daeyyjn®
undenWnd that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. SFI1 V'L LUResdut!
responsibility to notify the occupant of the requbr'menta which moat be and
prior to Issuance of a Certificate of Occupancy,
O vaer or authodred agent DateISSUED UY:]s
•lY`V W'1QANa/aVs
TOTAL:
OFFICE COPY