20198 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES— USE BALL POINT PEN ONLY
Bulldin Pm e<t Ideml(i<alun rExwrND.
Building Address: 20198
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rere one' A
CITY OF CUPERTINO-BUILDING DIVISION
centnct ' Name: uc.Ne: APPLICATION / PERMIT CG/
BLnDINGELECTMCA rLUMBING-MECHANICAL CATEGORY CONTROL N
Archlte / gtneer. Lk.No:
QTY ELECTRICPERMIT PPE BUILDING PERMITINFO
Address: PERMITISSUANCE 1:1y ❑
LICENSED CONTRACTOR'S DECLARATION �]O,
lumby
affirm that lam Bernardunder praChapter 9o(rommno
APPLIANCES-RESIDENTIAL JOB DESCRIPTIONInectton7000)of Divlslon3 ofthe Buelnessand EratesslonaCde,and my
license 1s 1.full
to.and effect. PANELS
License Ch Lle- �v23
Date D _ o Contactor 5
ARCHITECTS CLARATION 201-IOW AMPS
❑❑p!!p 70 I understand my phos shall be used u public records. OVER 1000 AMPS SQ.Fp.FLOOR AREA S/SQ.FT,
k o Licensed Professional SIGNS ELECTRICAL t
<<�4 OWNER-BUILDER DECLARATION BPFLULCIRCUIT/MI
Ihereby affirmthat l am exempt freen the Contractor's Llcense Law for the
following reaaon.(Sectlon 7031 S,Buelnese and rrolmbne Code;An tl or
county which requ lm a permit to contract,alter,Improve,demolish,or repair TFMP.METER OR POL
gany structure prior to Its issuance,also requ loss the applicant for such permit to ppyWElt DEVICES
[5 file a signed statement that he Is licensed pursuant to the provhloru of the
3l"tg
Contnctorb License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWEHMIN LELE VALUATION
1- O eion3ofthe Budnwand Protesslon Code)orthat hebaxemptthere(remand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permitsubjects the applicant to a civil penalty of not more than OUTLETS CHES
k*;RFA IV
° five hundred dollars(8500).
NEW RLSID E
�n ❑I,asowneroft the work,and n7 employee Intended
astheirsok SQFT. STOWES TYPE CONSTRUCTION
compersH .]a&.70K goadothewerkandthes ructum Code:Thrwtintendedororan1. r 1
,J sale(Sec.apply
Busi......d f peape oro Code:The or improves License hw
la $ does not apply loan owner of property,who Wilds or improve lhereeR and c OCC.GROUT' RFS.UNITS
0.0. whodaeasuch w not
f or dedorwgh his own e.If,however,
er,theprowided that ldingsuch
r
Improvements arenot Intendedearofcdtarsale.thh ew btheertidingve TOTAL:
Improvement h acid within oneycarofcompletion,theowner-bullderwlll have
tIi£IIuNen of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively mntnding with licensed PERMIT ISSUANCE
contractus to construct the project(Sec.7044,Business and Protesslora Code:
The Contractor's License Law cion not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or improve thereon,and who contracts for such plojech - -with a FEE SUMMARY
c7n4actor(O
licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
Las
I I am exempt under Sec. B&P C for this reason
QUTqI DE FEES
Owner Date DRAINS.FLOOR ROOF,AREA,GOND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT p
[]I hereby ffl.that I have a certificate of consent to self-inure,or FIXTURES PER TRAP C SCHOOL TAX Y N
certificate of Werken'COmPensationimurance ora certified ropythereof fSec. RECEIPT N
3800,Labe . GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
[Policy N RECENT N
Com an CAS-EA.SYSTEM-OVER4(EA)
Y BUILDING DI VISION FEES
Certified copy Is hereby furnished.
CertCREASE/INDUSTRL WASE INTERCEPTOR PLANCHECK Certified h filed with the city inspection flan division. FEE
CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi t#
Ohhsectlon need not be completed If the permit h Toucans hundred dollars
(s100)OHass.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that N the P= ce work for wMch this permit is issued, —
I shall not employ a I n caner m as to iect to the wp•IGR SYS.IEM/,I,AEA,IING
Woruos'Compen to a wan torn) e J PAID
O Z NOTApplICEt - NEW RESIDENTIAL PLMB, SQFT. Date Remi t#
Z O NOTICETonst. . NT:If fter making tiara CcrtBicate of Exemption,you
HshouldWrome sub' to the Werken'Compenation powhom ofthe L Wr TOTAL:
y Code,yaumuattorl Ith comply withsuch provhlorsorthh permitshall be BUILDING] deemed mocked.aCONSTRUCTION LENDING AGENCY SEISMIC FEB
I herebyaffirm that there h a mntructlon lending agency teethe perform
ELECTRIC FEE
LL02 anceer'.Naork(orwhlchthh permitblssued(Sec.3097,CIv.C.) TOTAL: a PLUMBING FEE
O Lender's Name
ly F L nders AQTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertllythatf ihaH have read ihkappllotionand state thattheabove information
hcomed l agree to comply with all city and county ordinances and stale law, PERMIT ISSUANCE FEES PAID:
C relating to building construction,and hereby authomee representatives of this
Z city to enter upon the above-mentkr,ed property for Inspection pu rpraes. ALTFRORADDTOMECFL
_ (We)agree to cave,Iedem ify an d keep harmless the City of Cupertino Date Receipt#
against liabilities, onsmand expenses which may In anywayaccree AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In ronial anceof the grantlegf this permit. AIR HANDLING UNIT(OVER IO,ODOCIT) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUC7) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous HEATING UNIT CIO 100,ODO BTU) Date Recei 1#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: x,-^
nYe, M No
Will theappllcant or future building occupant use equipment ordevion VENTILATION FAN(SINGLE RESID) ISRAM DATE
which emit haurdom air contaminants as deflned by the Bay Area Air
Quality Management District? BOILER-COMP QHPOR 100,0([0 BTU) 4 1990
Y. F�No APR
have read the ha oua materials requirements under Chapter 6,95 of BOILER-COMP 100,000 BTU[
the Ctlifomh Health&Safety Code,Section 25505,25533 and 25534. I
understand that if the Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH SQ.FT. City of(�IIIIP",.4,
RO
responsibility to notify the occupant of the requirements which must be met V
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Data ISSUIiDB`/r// �'RG-
TOTAL:
OFFICE COPY