20083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: /1 0 O/�l83/�
T 2 L
wnera arse: one; A
CITY OF CUPERTINO-BUILDING DIVISION
C°ntraaor's a Lic.No: APPLICATION /PERMIT
BUILDINGELECMUCALMUMBINGMECHANICAL CATEGORY CONTROL a
ArcMtect casae LIC.NIX
r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address IPLUMB MUCH
�
PERMIT ISSUANCE TV
LICENSED CONTR under SDICLARATIO
I hereby on7DOffirm hatlam BcensefthdRuinessand Pe fe aonsC9(m en AI'PL(ANCESRE9DEMIAL JOB DESCRIPTION
If...I Section force of d die°n3ofthe Businessand ProtessioneCode,and my
license Isins farce and died. PANELS
License Clae nft
Date.4/+3—esiU CoContractor � ✓,SLM TO 200 ANTS
ARCHITECT'S DECLARTION 201-1000AMPS
PCOC )understand my pians shall be used as public records. OVER1000AMPS SQ.FI.FLOOR AREA S/SQ.Fr.
U Licensed Professiowl SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION Spp-CIAL CIRCUIT/MISC
OH. 4 I hereby affienthat l am exempt from the Contractor's License Law for the
ZOQ followingreaeon.(Sectlon7I31S,Busineseand PrefenWns Code:Anytltyor TEMP.METER OR TOLE INST.
p� county which requlresa permdtoconsteed,alter,imprm
ove,deolish,orrepair
anystrocture prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3w� ComraaorsLicense Law(Chapter 9(comomming with Section 7000)of Divi- SWIMMING POOL ELECTRIC
kon3 ofthe Businessand Pro(eabruCods)orthat he is exempt lherefemand VALUATION
S° the baso for the alleged exemption. Any violation of Section 70315 by any [�t
< applicantfora permitsubjectstheapplicanttoa civil penalty o(notmorethan OUTLETSSWH'CHESHJ('I'URES t-a S_
Iva hundred dolowner
of he pr, NEW RESIDENTIAL ELECTR
�n m I,as owner of the property,or my employees with wages a thele sole c"Q'FT' STORIES TYPECONSTRUCTION
compensation,B. do the work,andthes Cede;
isnot Intended or offered for
q - sale(Sec.7044,Business and Professions Code:The Contractors License Law
3 does not apply to an owner of property who Wilde or improves thereon,and OCC.GROUP RES.UNITS
whodcessuchwork himself orthrough hisownemployms,provided thatsuch ^�
Improvements are not Intended orotfered fersale.It,however,themvWilding or TOTAL: /y.
impcmentbsoldwithinoneyearofcomplelorythe owner-bulleterwill have
I(,-kurden of proving that he did rot build or improve for purpose otsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE
qPN
I II L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �aa�
contractors to construct the project(Sec.7064,Business and ProceduresCode: v(J
The Contractors License law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER[FA)
Wilds re
da or improves theon,and who contents fee such pepleae with a
OqBE��metal licensed pursuant to the Contraelor's Limn Law. FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECD,p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP /ys SCHOOL TAX Y N
❑I hereby orkers that I have o Insurance
of consent d py themo ora U/ RECEIPT'M
certificate ofWorkers'Compensatl°nlnsurance oracerti(led copy thereof(Sec. GAS EA SYSTEMI WC40UELLTS
Polis Lab C.) . PARK FEE Y N
Policy q
ry
one any . GAS EA,SYSTEM-0RECEIVE qVER4(EA) BUILDING DIVISION FEES
Certified copy is filed hereby
the cityed. - CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copyb(iled with the city inspection division. s�eer�a _ _
CERTIFICATE OF EXEMPTION FROM WORKERS' G -i.\�I PAID
.mb.c.
COMPENSATION INSURANCE S � � ANIT�ARYSTQRM EA �(IQF�'•� Date Recei (#
(This section need not be completed if the permit blor°ne hundred dollars
mm)nifytht. ER HEATER WjVi T/ ENERGY FEE Y N
Icertitythat tithe performance of[he work for which this permit le laved,
I shall not employ any person In any manner an as to become subject to the WA SYS /TREATIN
Workers Com nonlaws of C.��IIf mia.D e y-a - ern PAID
O Z Applicant g F��__ Date Recei t#
Z O NOTICETOAPPLICANTfafter making this Certificate of Exemption,you .RESIDENTIALPLMB._ SQ.FT.
f" shouldbecomesobecttothe Wrk
oern'Compereatemprovedonsofthe Labor TOTAL:
LUW Code,you=at foe hwRh comply with such provisions or this permit shall be a
j deemed revoked. BUNG Q�
d 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lend ing agenry(or the perform- TOTAL a,a�k ELECTRIC FEE ♦ `
Z ansa ofthe work!or which lhls permit In issued(Sec.3097,Civ.C.) 2OaW
(� O once of'e Name PLUMBING FEE
LL1- Lendere Address ceQTY. MECHANICAL PERMIT FEE MECHANICAL FBE x,0
O W Irtlfythatlhavereadthie application siatethat theaboveieformation
IL is correct.I agree to comply with all city and county ordinances and state lawn PERMIT ISSUANCE 10 FEESPAID:
} N relating to building construction,and hereby authorize repementativeeo(this
Z city to enter upon the abovo-mentioned property for inspection purposes. ALTER OR ADD TO MECH.mkDate Reeei f#
— (We)agree to save,Ind enl(y an d keep harmless the City of Cupertino
against liabilities,judgments,mats and expenses which may In anywayacceue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
against said City N consequence of the granting of this permit.
AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrwtureof ApplicAZAR nOUS Date EXHAUSTHOODM/DUCT) '2`� CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wia the defined
by or
future building omspan ode, hapten le 9.IZandous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defected by the Cupertino Municipal Code Chapter 9.t2,and the �ax�a
HealthSafetyCod a Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yce es N No TOTAL: ♦W
Will the applicant orfutom building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardom air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OFT'OR 100,000 BTU)
Yes ad the ��11No A
havecl.Heath&Sefitymoerialsrequirementsundee Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �)
the Calitomla Health&Safety Code,Sections 2550.5,75533 and 25534.I
understand that lithe Wilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECEL SQFT.
responsibility to notify the occupant of the requirements which most be met p qQ
prior to Issuance ofa Certlficato. panty. /�aEU / ♦� '
Owner or authori gent Data 1i:
TOTAL �,� ISSUED BY:
rT
OFFICE COPY