20003APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE.BALL POINT PEN ONLY
Buiidieg Project Wentlfkat�en 1
Building Addmea:s't Vl e.^� -
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200,03
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLECAT
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O
Contractais Name: Lk. Nm
BU(I,DINGELQ:IRICALI'LIJMBINGMFLFIANICAL
CATFLORY
CONTROL
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add. H l Ste.
❑ ❑ �, ❑
IaFILWTI55UANCE
LICENSED CONTRACTORS DECW RATION
Ihembyaffr thatlamlkmsedunderpro W«uof Cbapter9(mmrnm
IngwithSMbn7000)ofl)i Wmr3otthe Butlnes.and Pmfe miCodga d
license Is In full force and d(nt
APPLIANCES -RESIDENTIAL
JOB DERITION
,.,.rte t
PANELS
Cha (-,
Dateme Comma.—., Tman MaC anical
211-1000AMPS
ARCHITECTS DECLARATION
lunderstand my plana slulbe used upubOc rnmds
OVER10DOAMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNS m DCDEECAL
Licensed Profs. lonal
SPECIALCItCUIT/hI-SC
OWNER -BUILDER DECLARATION
I hereby afOrm slut I amexempt from the LARAT n/s I.Icerue law (« Ne
following mum. (Semon 70315, Bushes and Profsmem Code: Any city or
oounty which requtrn a permit to corutrucl, alter, Improve, demnolbh, or repair
-�. ® I N
' t1
TEN`P.METQt ORIOLE WST. .�
any structure prier to Its imam ere, abo requUn the applianl for such pemJt to
Ne a signed statement that fr b il«naed pursuant to the provbiom of the
POWER DEVICES
l� 'TER
G i, {
ContraGole Lice. Law (Chapter9(mun
nendng with Section 700M of Divi-
don3 afths Businmand Profer mCWe)orthatheberempltherefmmand
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any vmlmtloo of Section 70315 by any
appBant fora permit subjects the applicant to a clWl penalty of not more than
fWe hundred dollin(sM.
n I, as owner of the property, or my employees with wages u their sole
O(TTLEISSWITCIIESFIXTURES DATE
�)
NEWRERDENTIALELEC7R SQFI.
STORI6
TYPE CONSIRIJCTION'
compensation, will do the work, and the structure Is not Wended or offe ilfor
.
Bale (Sec- 70K Bmbvs and Prv(mbm Code: The Comnctoe. Limme Taw
'
dorm not apply to an owner of property who builds or Improves thereon, and
who doessuchworkhlnuelforlhmugh hisownemployees, provided thatuch
OCCGROUP
RES ANTI'S
improvements am not Intended oroffered f«.ale. If, however, the W ildirg or
lmpmv memh.ddwhhlnorryardconTIdbn.theowner-buaderwW(uve
TOTAL
-
tIJ9,)2urdeo o(proWng that he did notbundorimprovef«purposeo(mb.).
LI 1 as owner d ad the property, am exclusively contracting with tlmn
contractors to mmtmct the project (Sec 7014, Busum and Pro(erbm Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
AI'N
PERMIT19SCANCE
The Contractors Lbeme Law don net apply to an owner of property who
Wilds or Improv Kneen, and who contracts for welt Mem with a
.Zractor(s) licensed pursuant to the Contractor's Licerue Law.
LJ I am eiempt under See- B & P C for Nb reason
ALS -DRAW & VENT -WATER 03N
.
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY 'Y_ N_
RFLEIIrI' !
Owner Date
WORKMAN COMPENSATION DECLARATION
k1 hereby .filmes that I love a certificated w « consent to self -Ire, a
Warkers'C«npematlon Iruunnce
FIXTURES. PER TRAP
TOOL TAX . Y N
RECERT
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y- N_
RECEITT e
«rulim a of «a ce"ieci copy thereof Sec.
3B00,Iab CJ
Policy. 067.004077 c)
GAS. FA. SYSTEM -OVER
Com Wa114eby TnS _C•Q
BUILDING DIVISION FEES
Cert
ip-$(icertNed ropy Is fiertgth the era,
CcrtlOed espy b filed with the dry Impemon dlvW m.
GREASE/INDCSTRL WASTE TNTERCFrroR
PLANCFIECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
'SEWER -SANITARY -STORM EA. 30�-1'.
COMPENSATION INSURANCE
(Thiol.need net Wcomplded Rthe permit 6f«one hundred dollen
Date RCLCI t#
WATER BEATER W/VENT/D.ECTR
ENERGY.= Y N_
(fI .)
I ¢rtlty tcemly that N the perfornwadthe wank (orwhlch IMm permit brand,
WATER SYSCEM/fREATINK:
I shall not employ any person in any manner so u to become subject to the
W«ken' Compensxbn I.. of California. Dan
PAID -
Applicant
Exemption, you
NOTICEco AITLIGttot
after king this Certificatero
NEW, RESIDENTIAL PLMB. SQFT.
Date Remi til
TOTAL
a Workers' is of Labor
emtfemlttothe
Code,shoulyou permitna
Code, you reset fmthwLLh comply with am provbbm orthh permit shall
much provisions ors
domed rewkld. '
BUILDING
SEISMIC FU
CONSTRUCTION LENDING AGENCY
I hereby affirm that thele is a consmactimn lending agency for the perforn,
anon of the work for whkh thb pemdt b hued (Sec 3091, clv. C.)
Lender'.Name
Icnder'. naa.
I certify thatl hats!read this appB tlonard mtatethdthe above Informetlm
hmrrtat.Iagme to comply with all city and county ordlnanm and nate laws
-ELECTRIC
TOTAL
a
FEE
QTY. -MECHANICAL PERMIT FEE
a
PLUMBING FEEMECHANICALFEE
PERMIT ISSUANCE
FEES PAID: -
rdding to W Iding mmtmman,and hereby authorize representativesof this
city to enter upon the mbovc-mentbmd property fee Wpectlon purpomea.
(We) agree to uve, i demmfy an d keep harmim Fentonthe Cry of Cu Fenton
.,.mu lleblBtles,Odgmentn,costsand e.pemn whkA may In any wayacvue
agaimtsmld Cttyinconrquene.fthgmmbgdthlsplmd[. ZS
ALTFRORADDTOMECH.
Date ReeCl t#
AIR BANDUNG UNIT DO 10,o0o CF7,0
SUBTOTAL:
AIR HANDLING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
St Nre of Appga « Date
EJ( HAl15T HOOD (W/DI1C0
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNT(TO IWOD0 BTU)
Will the appilom or future building occupant store or handle hazardms
material as deBmd by the Cupertino Munldpal Code, Chapter 9.12 and the
Health and Safety Code Section 75532(x)7
qY. No
'Jill the appham« tum Wading arts pant ua«rylp.m or devl®
which emit hazanloum air comemmams as de(Imd by the Bay Am. Air
Date Revel tlf
BEATING UNIT (OVER 100,000 BTU)
,
TOTAL:
VENTILATION FAN (SINGLE RESD)
ISWANC@DATE
BOIFR-COMP(3HPOR100,=ELEQ
Quality Management Wtrieti
4Yn QNo
havereadthe fimmuusmaterials rcqulrcm,nundcrChapter6.95o!
Jul•1 U (y&J
BO LER-ODMPOVFR 100,000 BTU
the Califomla Beath & SafetyCade, Sectt«u 75505, 75573 and 75534. I
'
NEW RESIDENTIAL MECH. SQ.FT
urdemandtlutifthe Wildingdoesnmcomntlyhaveatenam,thatltbmy
responsibility to notify the occupant of the mqulmmem.wlt" mast be met
Mi Of illnn,TfIBO
prim to lswamre daCenlflateo parry.
- 6
'-
s
ISSUED
O�ncr or authorlud agent Date
TOTAL
BY.✓AL�IL.U�A.a—vT
OFFICE COPY