20604 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PFRABi NO.
Building Address: 2 0 6 0 A
IoZ G 4
en one. APPLICATION SUBMI I JAL
>� CITY OF CUPERTINO-BUILDING DIVISION ���6
contmdnrme
. , : LieLAM .AM No: APPLICATION /PERMIT '-1�
G BUILDINGELECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL N
Architect/Engineer - Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: % 61& PERMITISSUANCE ❑ ElLICENSED CONTRACTOR'S DECLARATION
Thereby affbmts.tlam Bcen.edunderpm Wms.f Chapeer9(mm c. APPUANCES-RESIDEN17AL JOB DESCRIPTION.
tngwith Seelon7000)of Divigm3ofthe Businessand Pmfmk=.Code,and m
license 1s In full force and .O PANELS
Lkensc ClamC_ a9Lk.N 2 7(1(a's}�r
Date Contractor TSI—eR2 MA UP TO 200AM6
ARCHITECTS DECLARATION 201-1000 AMPS
1Q+�rx Zp I understand my plana shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E Licensed Professional SIGNS ELECTRICAL
66666 OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/AIISC
y s'iAa Ihereby affirm that Iam exempt from the Contractor's License Lw for the
lolimateg means.(Section 70015,Business and Profession.Code:Any city or
Fp county which requires,permit tomruhu"ter,improve,derrmlbeh,campair limp.METER OR EI
a any swcture prior to its Wuance,also requires the applicant for such permit to DEVICES.
U file a signed statement that he lavisl
licensed pursuant to the proom of the
3�G Contractor•.License lawiChapter9(commencingwllh SectWn7000)of Divi- NC POOL VALUATION
'
F,�OS sion3olthe Business and Profeasloru Code)or that helsexempttherefromand
O_ the bash for the alleged exemption. Any violation of Section 70315 by any O ETS
LM?c
applicant fees permit subjetroom.the applicant to a civil penalty niece room than
FIXTI
five hundred dollars hepr. ALELf TR SQFf. STORIES TYPE CONSTRUCTION
�n ❑Las ownw will do
property,or my employees with wage as[herr sole
compensation,wW dots.work and the structure b em attended or offered for
O sale(Esc.7094 Buelnese and Professions Code:The Contractae's Llcenx Taw
$ does not apply to an owner of property who builds or improve,thereon,and OCC.GROUP RES UMTS
EE whodeeasuchwarkhlm Umth=ghhi,ownemploym,prvvldedthat such
Impmwe ntsamnotintendedorafferfmwle.lChmw r,thebullding or TOTAL:
Improvement lssdd w thinoneyearofcompletlmbtheowner-bullderwBl have '
thLtlumden of proving that he did em build or Improve for purpose of ssle.). QT-y, PLUMBING PERMIT FEE FLOOD ZONE APN
u1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 7099,Business and Professions Code: PERMITISSUANCELV
The Contractors License Law does out apply to an owner of property who IZ
builds or Improves thereon,and who contracts for such pkajets with a ALTER-DRAIN&VENT-WATER(EN
CgR(rador(.)B...ed pursuant to thecornmtor.Ltmnae Law. FEE SUMMARY
LII am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y_ N_•
Owner Drte RECEIPT N ,
WORKMAN COMPENSATION DECLARATION PER TRAP SCI IDOL 7A% Y N
❑I hereby affirm that I havdflapp((UggS.e•cer
te of consent to self-insure,ora RECn NN
mrtlflmteofWorkers•Comper tlonlnsu..oracertifiedcopythereof(Sec.
CAS EA.SYSTEM-1 INCAOUTLETS x&I PARK FIE RECEIPT N
pedCom an�%dl-G�'IaGt—�LflMP CAS PA.SYSTEM-OVER N(EA) BUILDING D I VISION FE IS
CertNed copylshereby furnished. - GREASE/INDUSTRL WASfE INTERCEPTOR PLANCHECK FEE
MCertified copy is filed with the city inspection ciNt.lon.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANq•I•ARy-S1URM pA pOFi. Dale RCCeI IN
(Thi.sedfon need not becompleted if the permit to foram hundred dollars
($100)or WATER HEATER W/VENT/E.ECT'R ENERGYFEE Y N
I certidfyfy that In the performance of(hassock farwMds this paced(is blued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of Cel forma.Date PAID
O Applicant Date RCcet NSI
2 NEW RESIDENTIAL PLMB._SQ vr.
Z O NOTICE boo APPLICANT.to
after rs'Comakinpe Certificateavis Exemption,you
Hshould become subject to the Worken'Campeeaatlon provlslora of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be BU
ILDING FEE
LU 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL a M Ihereby afflrmthw them lsacoeWmctssued C&c. agency torts.perform TOTAL: ELECTRIC FEE
7 Z ance work/or which this pertnitblssrM(Sec.3097,Civ.C.)
V O tandem's Name - PLUMBING FEELL '
Lender.Address QTY, MECHANICAL PERMIT FEE
O W Icertlfythatlhavemadthbappllcatknandmatathtthe eboveinformatmn MECHANICAL FEE
1 In turretu
.I agree to comply with all city and county ordinances and elate laws PERMITISSUANCE FEES PAID:
>- W relatingtobulldingcoeauuctiogand herebyauthmice repmocatalivesofthls _
Z city to enter upon the above-mentioned propertyfor Wpectinnpurp... ALTERORADDTOMECH. Date RecCiptM
z (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,100 CFM)
against liabilities,Judgments,costs and expense,which may In any wayarome SUBTOTAL:
agabut old CltyInro s once o(ts. anting olthls permit.
AIR ITANDENG UNTf(OYES(10,000CFM) CONSTRUCTION TAX
Ignature (cent/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA Il and MATDISCLOSURE
Willtheappllcant or future building I pant store orluncile haaardous HEATING UNIT LIKE 100,000 BTU) Date Raaf t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCade Ion 25532(.)1 HEATING UNIT(OVER 100,000 BTU) TOTAL: l
❑Yn No
Will the applicant 6%w.building part.,a equipment or devices VENTILATION FAN(SINGLE RESID) ISSL%[�^DATE'
whkheManagement istrontamlnanta as defined by the Bay Area Air
Quality Management District? BOILER-COMP(311POR 100,IX0 BTU)yes o !'
! Dave read the haa�C usnaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �`v�t�
the Callfomia Health&Safety Code,Sections 25505,2S533 and 25539.I
understand that if thebuildingdoes not currently have atenanh that it Is my NEW RESIDENTIAL MECH. SQ.FT. ��P}���
responsibility to notify the..pant of the requirements which at be ms. Of 99�=
prior to issuance of a Certificate of Occupancy. �m
Q a
Owner or authariud agent Data
e ISSUED BY:
OFFICE COPY