21092 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmjeat Identification 7 PERMIT NO.
Baua163ry� �Om�Y���-S� 21092
TrWMrrn/a1 sine: D e: A A
iv1G�r �tL�l �_ �jd3d CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT < <^I 3-Q0
hmk, �' " BUILDINGS.FLTAICALPLUMBING-MECHANICAL CATEGORY CONTROLIf
Architect/Engineer. LIc.Nu
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(commenc APPEANCESRESIDENTLAL JOB DESCRIFDON
/Y ingwilh Section 7000).f MA,ton3ofthe Bueinessand Pmf,u.o Code,and my
If an i,in fu force and died.�(' _ PANELS ',L�• `,.'
LI¢nseC as - Lic.N
Date Contractor yrQ/
ARCHITECTS DECLARATION UU 201-1000AMPS
Q
Z I understand my plans shall be used v public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
Licensed Professional SIGNSELECTRICAL '
6 c% OWNER-BUILDER DECLARATION .(/
STELLAE CIRCUIT/MLSC
zt.., 7 that l am Business fromthe ctorb Licenw forthe
O Z O-.'� county hichrm owing r ssan.(dmaa n315,rmit totestoid anted Professions Code:se laMycityor ^eL
I-µ9 TEMP.MLTPR OR POLE 1NST,
any structuretatemeitshaaeIt alw reds pursuant to the provisionsorsuchpe
tto
o POWER DEVICES
c9,a U floe a signed statement That he(Chapter Ikeved pursuant it the bon 7 ons of the c
Ou, i..3adorsusins Law
rofew9Code)mcingwltexcrop"herexnnotm-
F,�O� sl.n3of the Business and Profenl.nCoae)orthat bass exempt there(romand SWIMMING POOL ELE C VALUATION
S yd the basis for the alleged exemption. Any violation of Section 7031.5 by any l^.
6 OUTLETSSWITC FIXTURES
pJ
applicant aper rs($5 Maths applicant to civil penalty room
Mi flue hundred dollars($500). c
❑• property, yemployees B NEW REBID AL ELECTR `•
I saownerofthe ro orowithot en .as their ��' I \ ' STORIES TYPE CONSTRUCTION
�7Q compensation Buwilsiness
andothe rkanathestode:Th Contrandedorofnse 1,a r
❑ sale(Sec 7014,Bu,N.s and Professions Code:The C.ntracto/a License Law r h ,(�
S� does not apply to an owner of property who builds or improves themrn.and1 qq
who does such work himself or through his own employees,provided that such - + 4 V 1 1 OC:.GROUP RIKI3NITS
Improvementsarenotlntendedorofferedforsale.lf,howevegthebuildingor INAL; -
improvement usdd wlthinoneyearofcompletlogtheowner-buBderwill have
t rden of proving that he did not build or improve for purpose of sale.). QTY. FLOWING HERMIT FEE FLOOD7ONE APN
LI,as owner of the property,am exclusively contracting with limmad PERMIT 1SSU` E /
mntracom to construct the project(Sec.7044,Business and Profession Code: a !x�
The Contractors Limme law does nest apply to an owner of property who
bu
ALTER-DRAIN k --WATER(EA)
Wild, or Improv.thereon, and who contracts such pta0cs with a v „
cq�[zcter(s)lfterm pursuantmthe Contractors Limrse Law. - FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PRpTFpk DEVICE— OUTSIDE FEES
DRAINS FLOORNOOF,AREA,COND.1 1 zSANITARY Y_ N_
Owner Date RECEPI N
•� WORK MAN COMPENSATION DECLARATION FIXNRF_4�ERYRAP SCIIGOLTAX Y_ N_
I hereby affirm that I have a l..te of consent to py,hn re,ora RECEIPT N
cern iLsb C.) orken'Compevatlonlnuragna or�a!¢ni(led copythereo((Sec. GAS EA. .1 INCAOUTLIE7
PoIcy,Nb CJO Z-W CG-ZIS3 / ' l-. _ PARK FEE Y_ N_
Rp
Com teens yH tN - GAS FA.SYSTEM-0VER4(EA) BUILDINGING DIVISION FEES
Certrfied copy bhereby fumf,hed. WWATERSY /TREAMIG
SIRL WASTE EPTOR PLANCHECK FEE
�ertmed mpy Is(ilea with the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' LAID
COMPENSATION INSURANCE
(rhissectlonneed not becomplded ifthe permit isforonhundred dollars ARY- RM EA.20011, Date Recei t#
($II oify that
R ENERGY FEE Y N
1¢rtify that In the performan¢ofthew.rk forwhlch this permit Is Issued, /VENT/ELFL7R N—
I shall not employ any person In any manner so ss to become abject lathe /TREATIN'GDate PAID
O Z ApplicantZ ON nCETOA PLICAM:ILaNermakingthlsCeniflote of Exemtionyou AL PLMB. SQFT, Date Remi t#
N should become subject to the Workers''Compewtfon provisions ofthe Labor TOTAL:
_ Code,you most forthwith comply with such provisions or this permit shall be
W > doemed revoked. BUILDING FEE
CL o CONSTRUCTION LENDING AGENCY MMECHANICAL
I hereby affirm that there u a covtoctlon lending agency for the perform E
7 Z arm of the work for which this permit E,ksaed(Sec.3097,CIv.C.) TOTAL:
02 Lender',Name EE
LL H lenders Addre„ QTY. MECHANICAL PERMIT FEE L FEE OW Icertlfy thatl have read thisapplimtion and statethatthe above Information1 Is correct.I agree to comply with all city and county ordinances and state law, PEiMITLSSUANCE , QQ relating to bul[ding concoction,and hereby authorize representatives of thiscity to enter upon the above-mentioned property for Wpection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Receipt#ago utlabfItk,i,)udgincra,c.stsand expenses which may In anyway accrue AIR FIANDLINC UMT(TO 10,000 CFM)agartyle conenmof the granting of this-. SUBTOTAL:1R/ aAIRHANDUNG UNII(OVER IQOOOCFM) ION TAX
Signature of Applicant/Contractor - /'Dace EXHADS'r HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA]AR DOLS MATERIALS DISCLOSURE
Will the applicant orfuture building.ccupantsmre or handhazardous
le HEATING UNIT(TO 100,000 BM 4z Date
mzterialas defined by the Cupertino Municipal Code,Chapter Alt,and the Ret:6 t#
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
E-1Y. n No TOTAL: ifam
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
.
Quality Management Distrkti BOILER-COMP(3ER'OR I(KI (q BTU) �J �
F1 Yet No t-
`-Ihavereadthehazy ouamatenats requirements underChapter 6.95 of BOILER-COMP(OVER 100,OW BTU)
the California I fra11h k Safety Code,Sections 25505,25S33 and 25534.I °y 1 z 1990
understand that if the building does not cormatly have a tenant,that it la my NEW RESIDENTIAL MECH. SQ.F7,
responsibility to notify the occupant of the requirements which rust he met
priorl�ksr.nce oja Cerlifiyate of Occur•-- - � � ..6 _
Ownerora5lh6'F2 t o -_� .e-.�--mate a 11- 1�sfyys4 ty Via.
I D �' TOTAL: ISSUED BY:�UE Alt- 4A-14+a.astrt
OFFICE COPY