20111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Pm cd leentlflcalon PFRh9TNO.
Building Adders: 17 0 1 11
G I
6k! ane. CITY OF CUPERTINO-BUILDING DIVISION , q�a
'sear aN""' `I\/ Lic.N.: APPLICATION / PERMIT
fo2les YN1 taSdp� BUILDING-ELECTMCALPLUMBING-MECHAMCAL CATEGORY CONTROLN
re itect/G � Llc.No:
,' ,a^ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adams: 11�S / ` � � PERMITISSUANCE ❑ El 1:1NAL.fff��ALIIC-EENNS===ED CONTRACTOR'S DECLARATION
Iherebyaffirmthatlamlicensedunderprovisloneof Cnapter9(¢mmen APPLIANCES-RESIDENTIAL ]OB DGSCRR'TION
Ingwilh Secion7000)of Division 3ofthe BusimsamdPm(essimsCode,and my
Rcense iglN luLLfpµp and dreg.5q_2 9 PANELS
License LION ,7'10"� l
Date%_I_Lpj"ARContnctor�p4. UP TO 2DOAMI'S
ARCHITEQ'S CLARATIOv7•� OVER
AMI'
po+0 CO I understand my plansshallbe used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E u Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCM7SC
Zt„ 3 I herebyamrmthat l am exempt from the Contractor's License law fee the
following mawn.(Semon 70315,Businm and Profmbna Code:Any dty or
F� county which requires a permit to construct,alter,improve,demolish,or repair TFMP.M L I
anystmc mpeortolt, swameaUorequlrestheapplicentformch permicto WERD
file a signed statement that he b Ikensed pursuant to the provisions of the
3 u,Iii Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. N C
SOS gon3ofthe Buslnmand Pro/mbm Code)orthat bebexempt therefromand VALUATION
O the basis for the alleged exemption. Any violation of Stolon 70315 by any T'C �/�
<
applicant fora permit subjects the applicamto a civil penalty of not more than J
five 1,as owner of (5500), MD ALEL SQ.FT. STORIES TYPE CONSTRUCTION
�n 60
❑I,ea owner l the property,or he employees with wages r their sole
m(Sec,7 Kflue othe ess.workandi..Ccdurebnot Intended orofferedfor
Ji D ule(See 7016,Bu.InesaaM Profmlov Code:The Contractone Llceme Law
FS
�yF d .notapplytoanowner erty
ofpropwhobuild.orlmpmnthereory and
oeOCC.GROUP R .UNITS
0.0. who doessuchworkhimselforthmugh Nsown employees,provided that such
bnprovements are not intended oroffemd(anile.U,however thebuilding or TOTAL:
Improvement b sold within one yeam(completion,the owner-budderwlll have
tlAtIumien ofproving that he did not bulla or improve for purpose ofule.). QTY. PL BING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively mntracting with licensed PERMR155UANCE
contndon to commuct the project(Sm 7016,Businm and Professions Cade:
The Contractor's License Lew don not apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
Wilda or Improves thereon, and who contrafor such ptojads with a FEE SUMMARY
Sm abadoas)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under SB&P C for this reason
Owner Doe
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Y
WORKMAN COMPENSATION DECLARATION RECEIPT
❑I hereby affirm that I have a¢rtlficate of consent to self-Inwrc,or• FIXTURES PER TRAP SCHOOL TAX Y N
RECEIPT N
380,LabC(Worken'Compematlon huunnce ora artl(kd copythereof t5ac. GAS-R&SYSIFM-IINCCOUILEI'S PARK FEE Y N
Policy
lab C)
Polity p - RECENT p
GAS EA.SYSTEM-0VFR 6(EA)
Com ray BUILDING DIVISION FEES
ncertlned copy is heed with the
ed.city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑CertNed copy b mea with the dry Impaction dlvlelon.
CERTIFICATE OF h3(EMPTION FROM WORKERS' GREASE TRAP PAID
-
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Recei of
Rbb. need n¢be completed lithe permit blur one hundred dollars
(5100)orlmcss.)3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I¢nify tis the performance of the work(orwMch this permit la iswed,
I shall note I any penoyJi ray manner an�6bjod to the WATER SYSTEM/TREATING
Worken'Co a IonL 11(omb. Date \� PAID
ZZ ApplNOUCn NEW RESIDENTIAL PLMB. SFT. Daft Recei t#
O NOT3CET PLIC :IL Re making/ s ertitlmte of Exemption,you
d ould become aubjM the mra'Compematlonpmvblomofthe Labor TOTAL:
_N Code,you st(onhwithcomplywlthsuchprov lomorthbpermitshallbe BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
t1 C l
I hereby affironflud w mere i a construction lending agency for the perform ELECTRIC FEE
0 O ance of work for which this permit bbeucd(Sec.3097,Cis.CJ
TOTAL:
V Lender's Name PLUMBING FEE
LL L.ender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlfythatl have mad thin application and statethattheabm
ove inforation
bcomea.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. W relatingto WildingmvtmniaM and herebyauthorize reprewntativesofthb
Z City to enter upon the abovnmentinned property for Inspection purposes. AL737t ORADDTOMECH.
(We)agree,to save,Indemnify an d keep harmless the City of Copan loo Date Receipt#
V against Babiltla,judgment,.9...d e.pen¢.which may In any way amu. AIR BANDUNG UNIT(170 10,000 CFM) SUBTOTAL'
spinal said City in conaaiu ence of the grant leg of this penult.
AIR HANDUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date FXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occo pant store or hand Is hazardous HFATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ye. MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cndt hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
�i�f Yes n No
Ihave¢adlhehavr7usrtutedabmquimmenbunderChapler6.95of BOILER-COMP(OVTR 100,000 BTLA
the Celifoob Health&Safety Cede,Sen lom 25505,25M3 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESI DENTIAL MECH. S'Q.FT
mpomito notify the occupant of therequi¢m ot.which must be met
prior to I s once of a Certificate of Ocm panty.
to au
ax
neroraulho' da t Datelsl;UEDBY:V�
TOTAL:
OFFICE COPY