20615 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Nc
gBulldin Pmect -Identification PTNO.
290 G�IULLT bAl 20615
_ nes ante: one: AITUCAI ON SUUMIHA=
'�'�I L• EITm far CITY OF CUPERTINO-BUILDING DIVISION /_ 2-7
cmtnctor'.Narre: APPLICATION I PERMIT `v
BUILDING-E.FCTRICAI PLUMBING-MECHAMCAL CATEGORY- CONTROL#
Architect/Englneen Lk.No: BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address: PERMIT ISSUANCE ❑ [I ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby s/trmthallam Ri.3.fhunder B"rovWmeol ChapteC d.,amme- APfeLIANCESRESIDENML JOB DESCRIPTION /
Ineraelal fullf000)of Dldfect. Qhe BuYnemandlarolesaloneCode,end my - _C
Ilans le in!sect f and effect. E–p � PANELS / /� � /7
License late• Lic# e'r Jam✓ CJ/'
Date Contactor O pl T�
ARCHITECTS DECLARATION
AMRS
oZ l understand my plane shall be used a public records. OVERI=AqPS I SQ.Fr.FLOOR AREA S/SQ.Fr.
CO
(� Licensed Professional SLGNSEL~ '
`fEdu OWNER-BUILDER DECLARATION U C
t., Ihembyaffi.thatl am exempt frmnthe Contractor's License Law for the
ZO f. following reason.(Section requires, m7031S,Business,and Pretenders Code:My city or LE
�� countywhich requla pedttocurutroct,alter,Improve, m
dealbh,orrepalr
q' an b ystm=mprlortolt•Issuance,alwrequimslheappBantforwch permitt
1 D g
O 6 Ole a signed statement that he licensed pursuant to the provisions of th ,
36{{-�� Contactors License Law with Section 9W D)of Dlvl- Q- VALUATION
1 Yon3o(the Buamsand Profmbm Code)orthathelsexemptthon, on.nd
4 a.•,]] the Gab for the staged exemption. Any violation of Section 7Q)1S by any (M I pl SWITCHESES
applicant fora permit subjects the applicant to a civil penalty dno[morcthan 0001
tiv�e f�undred dollars($SM.
1u as owner of the m NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n p party,or my employee with wages r[hale sole
compensation,,Businessl do workand the strodureh not Intended or offered for
O sab(Sec.76N,Business and Prefeniom Code:The Contractors License Gw
� . does not apply to an owner of property,who builds or improves thereon,and OCC.GROUP RES UNITS
EE who does such work timeelforthrough hlsown employes,provided that such
improvemerRs are not Intended aroffered for sale.If,however,the building or TOTAL:
improvement Issold within one yearofcomplation,the owner-builderwEl have
ll,&�urd on of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7014,Business and Professons Code: PFRMUISSUANCE
The Contractor's Limns Law don not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves themes,and who contracts for such pce(eces wish a FEE SUMMARY
cgnjLactor(e)licensed pursuant to the Contractor•Limns Law, BACK FLOW I'ROTF]CT.DEVICE
lJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT Y
WOR XMAN COMPENSATION DECLARATION
MI TAX Y N
❑I hereby affirm that I have a cortifiahl%'NRRS PER TRAP te of consent to self-insure,or RECFRT N
certltlateofWorkers Csnpensationlnsurance or a cortified mpythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARKFFE Y N
3800,Izb C.) RECEIPTNM
nry Y GAS PA.SYSTEM-OVER 4(EA)CoCsay � BUILDING DIVISION FEES
dCedlfled copy b hereby famished. CREASE/INDUSRRL WASTE IN'I'EtCEPTUR PLANCI-IEGIC FEE
F1 Codified copy b filed with the sty Inspection dlvlelon. -
CERTIFICATE OFE(EM"ION FROM WOR KERS' GRFA-SETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.ZWFf. Date Recei t#a�•��
(This section need on,be completed if the permit is for one hundred dollars
(EI0(Borless) WATER HEATER W/VF3VT/E.FiCTR ENERGY FEE Y_ N_
Iartify that ioth derma �h ..?.fr:hlrhethle peoNt ie lamed, ,
I shall not ample y person I t sp3ee qqts ryp�theWorkers'Comnlawe f te �`T –/U WATER SYSTPAI/TREATING PAID
O Z Applicant 90 —
Z O a NEW RESIDENTIAL PLMB. SQdT. Dale Recel t#
NOTICE ICON :I, IC (Ex
should me abject tot ar ngt er�Bkatooemption,you tkers'Cum nsatlonprovblonsofthe Labor TOTAL:
N Cudr,younwstiorthwi ply wdthvrch provlsionserthb pertNt•hallbe
ILDING
W j deemed revoked. . BU
CONSTRUCTION LENDING AGENCY $ ISMIC FE
0. I hemby,atfirmthat then b a construction lending agency for the perform ELECTRIC FEE
Z ance of the workfor which thin permit in Weed 15eo 3097,CI,C.) I TOTAL:
00 Lender's No PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
LL U Icortilythat l havereadthi•appliationand statethattheabove Information MECHANICAL FEE
O 1 bcorred.l agree to complywith all city and county ordinances and Yate laws PERMIT ISSUANCE FEEJ PAI :
N relating to building conatrectdon,and hereby authorize representatives of this
Z city to enter upon the above-mmtloned property for inspection purposes. ALTER OR ADD TO MFCH.
(We)agree to save,indemnify an d keep harmless the City of Cu ped[no Date Receipt#
V agaWt liabilities,Pdgments,"aand expenses which may In any way accrue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:.
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocav pant store or hand Is hazardous HEATING UMT(TO 100,ODO BTU) Date ReceI t#
material as den red by the Cupertino Munldpal Code,Chapter 9.R,and the
Health and Safety Cod Uan 7M32(.)?3I(a)7 HEATING UNIT(OVER 100,000 BTU) AL: O/^
y.
❑WIIho esppliant building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 1$$ ONCE ATE
which emit hazardous air contaminants as defined by tM Bay Area Air r
Quality Management Dist ctt BOILER-COMP OFT'OR 100,003 ETU) JUN 2-v 1990
4Yea No
1 ve mad the hoz o rtutedals requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,0000#)
the Call(ornb Health&Safety Cod 1 m 75505,25533 and 25534.I �G
understand that II the
build
ln ca no rnnlly have a tenant,that It Is my NEW RESIDENTIAL MECO. SOFT. 'PC_��'••�
rmpom[b.W lona eo paen
nt the requirements which moat he met
pdorl arroc (flat caapancy.
�- Yo
Data TOTAL: ,�
er or mut raze ant )lig
OFFICE COPY