20830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
But din Pr en Identlfl tion L`r. PRILMIT NO.
Building Address:':1 Q ie ,� ` Y ` 3 7 7 - 7 9� p - 20830
7!i5 1-47 L4C4( jQ11Q_
O� <
,.CITY OFCUPERTINO-BUILDINGDIVISION qD
cnno-adnr's Nacre: `.Lie.Nn: APPLICATION /PERMIT
rehired/Engineer. Lk.No: BT2LDING-ELFGTL4ICA4PLIIMBINC-MLCHAMCAL CATEGORY CONT{[`
:r' - "BUILAING PERMIT INFO'
EI:BGTRICPERINIT , .-�.FEE:• •'�-;' .
Addrcsc [ _ PPRhIITISSUANCE k,O tIC7T
LICENSED CONTRACTOR'S DECLARATION �-
I hereby affirm that l am Ikensed under provisions of Chapter9(mm
mene- APPLIANCFSRESIDEM'IAL ]OB DESCRI'CION
Ing with Section 7000)of Division3 ofthe Businessand ProfessionsCode,and myinen -
Date els l� nf'O=o Q�Lxnzd effect. ' 3 5 LTT02 `� Poe f
PANELS
LlcenseCWm—, W /Y �
Date ContractorRvinla
ARCHITECTS DECLARATION.q�� OVER0 S
AMP
qaOz Iunderetand my plans shall be used as public records.de. 100 AMPS SQ.FT.FLOOR AREA $/SQ.FT. 'u O
d Licensed Professional SIGNS ELECTRICAL
�<<< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
zf, I herebyaffires that lam exempt from the Contractors License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or -
r 1"u9 countywhkh requires a permit in construct,altep improve,demolish,or repair TEMP.METEROR POLE INST.
.a anystructom prlorto its Issuance,also requimatheappllcant forsuch permit to
file a signed statement that he Is licensed pursuant to the powblone of-the POWER DEVICES
Contractor's License Law(Chapter 9jearmencingwith Section 700)ofDlvl-
�0� sion3o(the Business and Professbru Code)orthatheb exempttherefromand SWIMMING POO EL C7 U� VALUA•L19N
the basis for the alleged exemption. Any violation of Section 7611,5 by any �' L%
Q
applicant fees permit subjects the applicant toadvil penalty o(not more
than
5
GG77 fie 1,aso demo the pr). �p g - " g RIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compers ti.mwilldethe work and thestructure b not intended or offered for
sale(Sec 7044,Business and Profession Code:The Contradoes License Law
does not apply to an owner of property who builds or improves thereon,and DATE '1 OCC.GROUP RFS.UMTS
who does such work himself orthmugh his own employees,provided thatsuch
impmvement"m rsatIntended oroffered for sale.If,however,thebulldingor TOTAL: .�Q
Improvement baold MthinoneyearofcomplettoMtheowner-buBderwlll have
t119-kurden of proving that he did not build orlmprove for purpose ofsale) ('2TY, ;' "PLU11'IBIN PERMI`F �''FEFu?' FLOOD?ANE APN
U 4 ae owner of the property,am exclusively contracting with licensed ppgMlT ISSUANCE
contractors construct nstruct the projed(Sec 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER(FA)
Wilds or Improves thereon,.and who contracts for such plojects with a
Cc,Ilt.[aeo dor(s)licensed pursuant to the Contractors Limme Law. , RACK FLAW PROTECT.DEVICE _O
LJ I am exempt under SB &P C for this reaxon,
OUTSIDE FEES
Owner Date DRAINS FLOOR,ROOF,AREA,COND. _ D SANITARY • Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a certificate of consent to self-insure,or FD(TURF&PERTRAP aD O SCHOOL TAX Y N
centfimteofWorkers•CompernaHontr mnremamrtifledmpythereof(Sec. RECEIPT
380,Lab CO GAS EA,SYSTEM-1 INCA OUTLETS �0PARKFEE Y_ N—
Policy# RECEIPT#
Com any GAEA,SYSTEM-OVER4 LEA) BUILDING DIVISION FE ES
❑CertifiS ed copy is h.rc y furnished.
F-1Certifiedcopy b filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
76
CERTIFICAEXEMPTIONRWORKERS' _ GSE r
COMPENSATIONINSURANCE PAID
Rhleslets.)ection need not be complded i(the permit is(Drone hundred dollars SEWER-SANITARY-STORM EA.TOFT. Date Receipt
($10)orWATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I ll s t that employ
an person In an [re&thls to b e per It a issued, C1
I shall not employ any,Laws in any mto bee d to theWATER SYSTEM/TREATING BP Ownnkere'compeneanon Lava orCaummPAID0 Z Applicant NEW RESIDENTIAL PLMB.Z NOUCETOAPPLICANT:I,aftermakirif mp n, ou SQFT. Date Recei t#ahwldbemme subject totheWarkeri CIsi eL bonTOTALCode,youmustfoet.ithmmplywithor 1 RheBUI ING •• Ob� deemed revoked.aCONSTRUC JON LGE SEISMIC FEEIherebyafflrmthatthereisam uca` racy or the perform- ELECTRIC FEEZ anceofthewrk forwhkh thf per l4y,Cie.Q TOTAL rs V0 f.ender'sName - t PLUMBING FEE 2 ,
Il I— Lend. 9Addma9 QTY, MECHANICAL PERMIT $: ' MECHANICAL FEE
O 111
Icerti(ythatl love read thieayy tin thatiheabowlnfomatlw
1 Is correct.I agree to complywitHa11 my edinances and slate laws PERMITISSUANCE FEE$PAID,.
} N relating to building mrmtmdion,and he byauth cropresentatives of this
(— Z city to enter upon the above-mentioned roperty for Inspection purpose,. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Da[e Receipt#
against liabilltles,judgmenb,mA.. dexpen a which may In any wayacnue AIR HANDLING UNIT(TO 10,00 CFM) SUBTOTAL:
sgai�sid City In conseque o(the gr ng o(this pem.it.
,r AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX ,
I
Signature ot ���onbbbtra r Date EXHAUST HOOD(w/DDCT) CONSTRUCTION TAX PAID:
HAZA RDOUS MATERIALS DISCLOSURE
Willtheapphm it or future building occupant store or handle hazardous HEATING UNIT(TO 10,100 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Recei t#
I and Safety Code Section 25532(a)? HEATING UNIT(OVER 10,00 BTU) TOTAL:
❑ Yes �]No'
Wulthe applicant orfumrebuilding ompantuse equipment ordevlms VFIMLAT'ION FAN(SINGLE RESID) ISSUANCE DATE
which emit named.,air mntamle.m.a,defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,00 BTL) _py�,��
Yea nnNo Wrr-O
have read the hau'i 0realerialsesqulrements un derChapter6,95of BOILER-COMP(OVER 10,00 BTU)
the California llealth&SafetyCode,Sedion,25505,25533 and 25534.I
understandthatifthebuildingdoes m.rr rally haveatenanythatitlsmy NEW RESIDENTIAL MECH. SQ.FT. It
responsibility to notify theocmpant of th quirements which must be and ;{ A Q
prior �ss race ofa Ccd'fi.�m Oc ancy. yla,{� Fi V
Owner or authorized,gen Dace
ISSUED BY., ev d
TOTAL;
OFFICE COPY