20707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE,BALL POINT PEN ONLY
N.itdl.g Pro'ertldentification PERMIT NO.
Building Address:
2070.7
0.7
nerd ams: one:
A A
CITY OF CUPERTINO-BUILDING DIVISION —1^` C^ `o
'.m ic.No, APPLICATION / PERMIT
LAO BUfLDINGELECTRICAL-PLUMBING-MWHAMCAL CATEGORY CONTROL// O
rchitect En neer. Llc (y
�aS QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ' PERMITISSUANCE ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
El
I hereby affirm that l am licensed under proviseonof Chapter9(mmmene- APPLIANCFS-RESIDENTIAL JOB DESCRIPTION
ingwith Section700 )of Divi,lon3efthe Businessand ProfesNonsCodgand my a
license to In full force dna affect. PANELS
License Class Lk.#
Dale Contractor —UP TO 2DOAMPS
ARCHITECTS DECLARATION 701-1000 AMPS
mO Zp I understand my plain shall be used as public records. OVERIOOOAMPS SQ.Fr.FLOOR AREA S/SQ-IPL
Licensed Professional SIGNSELFCTRICAL
OWNER-BUILDER DECLARATION
SPFGIALCIiCUIT/MISC
y t"' owing axon.(Satlam 31.5,8xempt(romihed Professions
Code;
Law for the
qqqqqq following reason.(Section 7031.5,Business and Pro(easlons Code:Any city or
G t' cauntywhichrequimaper ttommtmct,alter,Mpmve,de=lR h,orrepair TEMP METER ORPOLE[NSF.
q� any structure prior to its Issuance,also requires the applicant for such permit to ppyygg DEVICES
f5 file a signed statement that he I.licensed pursuant to the provisions of the
G670 u,(f-, Contravenes License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING[VOL ELECTRIC VALUATION
e, OJ slon3o(lhe Business and Profemloru Code)orthat he Vexemptthere(romand
6 the basis for the alleged exemption. Any violation of Section 7131.5 by any OUTLETSSWITCHES-FIXTURES
appnrant fora permit sub*tsthe appbcantto a civil penaltyof not morethan
five I,asotlnerofshepro NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with waged r there dale
compensation,will Business and
work,and the structure Isnot Intended L offered for
O sale not. ply Bu sinessandf property Code:The Contracteesthemelaw
$ whodot apply roan owner ofpropertyhisabuilds or improves nemplyees,povidedreoryand OCC.GROUP' RES.UNITS
who oves such mentswork himself ed oroughed own¢.It,ho ea,provided that such
improvementsarenot Intended earofco for eate.If,however, deerbuilding e TOTAL:
improvement Issoldwithlnoneyearofcompldion,chc owner-bullderwill have
flillIturclan of proving that he did not bund or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7014 Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law dcea not apply to an owner of property who ALTER-DRAIN&VENT WATER
Wilds or Improves thereon,and who contracts for such plojecta with a - FEE SUMMARY
on,0tt.[[actor(s)it= and pursuant m the Contractor's License Law. BA �'.D C
LJ I am exempt under Sec B &P C for this'reason OUTSIDE FErS
DRAINS r RA00$AREA CO SA TARY Y N
Owner Date - n RECEIPT#
•, WORKMAN COMPENSATION DECLARATION
❑ STIS]' I I u I SCI LTAX Y N
I hereby affirm that I have a certificate of consent to self-InsurepgyQgEPE
,or ✓J RECEIPT#
3800,Lab C.)
certlfimteofWorken'Compematimrlmun moramAifiedcopythereof(Sec. GAS'FA.SYSTEM-1 INC.40UIL PA FEE Y N
Policy# _ RECEIPT#
Com any GAT. .SY MfyJft — - BUILDING DIVISION FEES
nCertified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
❑Certified copy It filed with the city inspection dleidea.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP _ PAID c�-tl-�t
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7WFT Date Recei t# S F*
ONssevelan need not be completed[the permit V(Drone hundred dollars
($10amfyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
chat o the person
in annce manner so as to b this become
esubjermit c Eroed,
I Whale not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of CeRfomla.Date PAID
0 Z Applicant RESIDENTIAL PLMB. SQFr. Date Races t#
Z Q NOIICETO come su ICAtothe after makinrs'Co perhis 'tion ro o(Exemption,eLyou
F should become mbjen[o the Worken'Comperoatlon provtamm of the Labor TOTAL:
~ W Code,you at forthwith comply with such provide.or this perrNbhall be
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE tCG
IL I hembyaffirmlhat there b a construction lending agency for the perform ELECTRIC FEE
M 0 ance of the work for Mich thii permit b doued(Sec.3097,Civ.C.) TOTAL:
V Lender's Name n'j x - PLUMBING FEE
F Lceder'eAddresd QTY. MECHANICAL PERMIT FEE
LL - MECHANICAL FEE
O W [cerci.Iagretocomply eappncityndcountethatthea�yorellearms and
C isctingto agree to comply tion,andtyandrountyorclnances and date
solaws PERMIT ISSUANCE FEES PAID:
>. relatingtobulldingrorulmctmmtiordpropd hereby authorize representativesof
H N city to enter upon the abovcmentbned property for inspection purposes. AL77R OR ADD TO MECH.
? Me)agree to save,Indemnify an d keep harmless the City of Cupertino Date Rotel t#
V against liabilities,judgments,e.g.and expenses which may In any way attme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
'gal teaid City in consq artm,fthegriortingeithespe I' AIR HANDLING UNIT(OVER Io,"CEM) CONSTRUCTION TAXSfgfe '
126/9 1.) AIR
TAX PAID:
toren App)kant/G °r —atl� EXHAUST HOOD(W/DUCT) -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Cade Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes n No Ivy
Will the applicant or town,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISEMSIDATE
which emit hard rdous air contaminants as defined by the Bay Area Air
lity Management District? BOILER-COMP 0HP OR 100,000 BTU) AL ®a (�V
❑Yca reze 1—I m
No 199V '
[nave ad the haus aterlalsreIrcments under Chapter 6,95 of BOILER-COMP 100,000BNI A
the California Health&Safety Code,Sen lone 75505,75533 and 25534.1
understand that if the building does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which most be con OE.CURBI't!R�
prior to issuance of a Certificate of Occupancy.
' r
Owner or authorized agent Date ISSUED Br.-J, N,' O Yk'/
TOTAL:
OFFICE COPY