20619 APPLICANT LIN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulidln Pro'ca ndficaivn PERMIT NO. ..
uild
B 2gg (7 C.,1-"Fr 1LL 20619
ere aces: one;
trt�aatof--ppgc,Kl N rz CITY OF CUPERTINO-BUILDING DIVISION A
Cmtracer(y�Ya�m�e: r ¢Lyn: APPLICATION /PERMIT &
saw '- I BUILDINGdECTRICAt-MUMBING-MECHAMCAL CATEGORY CONTROL tl
Architect/Englruer. Lle.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERMRISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'STs DECLARATION ILS
IMhSMiolrmthat(Dimscn3oftNunder ukp andps fh..r9(commmc APPLIANCES ENTIAL JOB DESCRIPTION
Ingwlth5M1on7000)of DlWalan3�o1(tF/eBu/a�lneuand ProfesslmsCyde,and mylicesse �/Y.`' �j (j
Llcensela o and off Y /mob 7�D q pis ( C I M/'r/Z 7S iG F-
Date CaMncmr_ -{�— ' '
ARCHITECTS D IBC \IU710P 201-1000 PS 11
m20 I understand my Platte shall be used as public remrda. OVERT 5Q.FT.FLOOR AREA f/SQ.FT.
God6j Licensed Professional SIGNSELEC CA
<<�� ffiK OWNER-BUILDER DECLARATION SPECIAL -
ZIo-• ? Ihereby armthat l am exempt from the Contra"me.License Law forthe
NX
O Z c. following reawn.(Section 70)75,Bueiner and Pra/essiuns Code:My cityor p, LE
F� countywhichrequlreeapermitWmrutmMatter,impmve,dennlbh,orrepalr -
qqq anystmmmpr rtolb Wuance,al ngulrestheappllantlorsuchpermitto �gIXq
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law(Clw er9(commenM with l" B SK NG IA70L ELECTRIC
O kan3o(the BusinessandProfembtuCade)orthat hebexem therefromand �.�(� VALUATION
!. 6 the basis for the alleged exemption. My violation of Section 703(.5 by any SZ TS-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not mmethan T/
five hundred so dollars 0500). NEW RESIDENTIAL ELECTR SQYr. STORIES TYPE CONSTRUCTION
❑/,as owner of the property,or my employees with wages as their sole
comperuation,wBldothe work and thestructure b nm Intended or offered for
O ssle(Sec 70M BusAnessand Pmfedimu Code:The Contractor's License Law
$� does not apply to an owner of property who Wilde or improves thereon,and OCC.CROUP RES.UNITS
whu does euchwarkhimselforthmuagh hbownemploym,provlded thatsuch
Improvements am
ot nIntended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearofcomple ion,the owner-builderw111 have
tryc.¢arden of proving that he did not build or improve for purpose of sele.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
LI L as owner of the property,am exclusively contracting with licensed
contactors to construct the project(Sec.70K Businenand Prof.imu Code: PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER[EA)
builds or Improve thereon, and who contracts for such p(uje ,with a FEE SUMMARY
rypjpdor(s)Ilansed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
0I am exempt under Sas. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y_ N_
01 hereby af(Irm that I have a ceMOate of consent mself-Insure,or RDCETST N
3800,LmrtifiaabC.)
rken'Comperoadonlnsursnn ora artlfled copylherte!(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARKFEE Y_ N
Policy
N RECERrT N
GAS EA.SYSTEM-OVER 4(EA)Com ny BUILDING DIVISION FEES
❑Cert filed copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Cerliffed copy Is filed with the city Inspection division.
2"1 CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date RCCeI t#
(Thlssectlon need not be completed if the perrdt is forone hundred dollars
($100)orless.) WATERHFA77RW/VENT/FT.FGTR ENERGY FEE Y_ N_
I certify that in the performance of thework forwhich this permit is blued,
I shall nor employ any perann in any runner so as to become subject to the WATQt SYSTEM/TREATING PAID
Workers'Compensation lawsof California.Data Z Z ApplicantNEW RESIDENTIAL PIMB. SQFT. Date Recef t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compemuation provisions of the Labor TOTAL:
W Code,you=9 forthwith comply with such provisions or this permit shall be BUILDING � mil
W > deerxdrevoked.:
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL G Ihereby afOrmthat there b a construction lending agency for the perform - TOTAL; ELECTRIC FEE
O ance of the work for which this permit b Issued(Sec.3097,Civ.C.)
Lender's Name PLUMBING FEE
LL I- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iortify that l have madthbapplicetiunand kalelhattheaboveinformatlm
a correct l agree to comply with all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID:
T relating to building construction,and hereby authorlu representatives of this
F 2 cityto enter upon the above-menuorud property for impectton purposes. ALTER ORADDTO MECH. DatC Recei f#
_ (We)agree,to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,Odgments,coke and expenseawhlch may in anywayamrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL
against said City in�seaerm;f the a g of thls permit.
M
' CC1,�1 AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signature of Appllant/Contractor ' Data EXHAUST HOOD N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Niure building occupant store or handle hazardous HEATING UNIT CIO 100,DDD BTO Date RCCei [#
material as defined by the Cupertino Municipal Cale,Chapter 9.12,and the
Health and Safety Codas dion 25532(a)2 HEATING UNIT(OVER 100,000 BTO TOTAL:
RYes biaq.
ill the applicant c7uhrebuilding occupant useegWpment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Nr '
Qua lity Management Db d7 BOILER-COMP OTR'OR 100,000 BTO
4Yea No �H u (3C3
have read the h Jo us materials requirements under Chapter 6.95 of BOR.ERLOMP(OVER 100,000 BN) �UI\ V 1.7.70
the Celifomla Health&Safety Code,Sectlom 25505,25533 and 25534.1
understa rd that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
resporuibllity to nilly the occupant of the requirements which must be met CItY Of CUBP.1'�gQ
prior to Issuanceof�lfirateo Oc parry. JQV 417 tai
Ownero�ra�,/h/o4�rJize.agent Date ISSUEDBY:`'
TOTAL,
OFFICE COPY