20498 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - t PERMTNO.
Bullding' ddmes: v f�O A 1�
� G 4 .9
OwnersName: one.
�>"[09I eS CITY OF CUPERTINO6BUILDING DIVISION
c°"iradnr.Name: 415-ciaga4-- r(" APPLICATION I PERMIT 3 L v
BUILDING-ELECTRICA4PLUMBINC-MECHAMCAL CATEGORY�' CONTROL N
mh a Engineer. Lie Na'
3['182,}19 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ad as s� 1 C C. -1 S(J� PFRMTISSUANCE ❑ El 1:1LICENSEDCONTRACTOR'S DECLARATION
I hereby affirm that l am hemsed under provWona of Chapter 9(mmmove APPUANCES-RESIDENI1AL JOB DESCRIPTION
Ingwith Sedion7000)°f DtWsion3oftheBadnenand Pmfneons Code,and my
license is In full force and died. PANELS fin/ y3
License—A Cmd,, i�nAr (I Q D� y� PA,,IAT
Date 1Cl. 1—GI Contractor '�"-'
-_—a ARCHITECTS DECLARATION MI-1001 AMPS
oZ IundentarW my plans aha8 be used republic records. OVERIIX)OAMPS SQ.FLFLOORAREA $/SQ.FT.
O
ILicensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
I-n� am SPECIALCItCUIi/M15Gc
t,., Thereby a(firmthat lexempt lromthe Cont ractare License Law(or the '
Z O.. followibg reason. el
(So"70315, en Busmand Pmfealons Code:Any dty or
OZ1..� TEMP.METER OR POLE INS-TS f
Kcountywhkh requires apermid
ltocoustn ,cites Improve, m
deolish,orrepalr
9'`a janystmmm print to itstssuaace,elsomquires the applicant forsuch permit to POWER DEVICPS
file a signed statement that he is licensed pursuant to the provisions of the s
0 w Contractor'.License law(Chapter 9(mmirenring with Section 7000)of DIA- , V LUATION 0
30� xn3cftha Buslnnsand Pmf.I.ax Code)orthat he isexem thrmhomand SWN1hINC POOLQ C O
P'��,6 the basin for the alleged exemption. Myt to
olatbn of nachos 70)15 re any O ETSSW[IC FUCIURES //^^
applcan red delta.
the applicant Toa dull pemltydnd more than • 1,`\ V
E(y a flue hundred dollars he pr. NE CSIDENTIAL ELECTR SQ.Fr. J
owner of the property,or my employees with wages as their a°Ie y �-+ - STOW TYPE CONSTRUCTION
C < compensafl°n,will clothe work and thestmdue is not intended or offered for 15 ) �l ( \1
q D sale(Sec.7014,Busmenand Profession,Code:The Contrator's License law -
�$ does not apply toanowner of property who builds or improve,thereon,and r J '� /
who does such work himelf orthrough Ms own employees,provided that such - 1 OCG CROUP RES.fINHS
Improvements are not Intended oroffered tarsale.If,however,thebuilding or TOTAL:
improvement iswld wlthlnoneyearofcompldiogtheowner-bullderwlll have
t1}c¢+rden of proving that he did not build or Improve for purpose ofwle0. QTy, L BI GPERMI FEE
U L as owner of the property,am exclusively contracting with licensed FLAQD ZONE APN
contractors to construct the project(See 7044,Buaim..nd Profeeloru Cods: PERMIT LSU ' E lj
The Contractor's License law don fiat apply to an owner of property who
buALTER-DRAIN k- -WATER(EA)
wild.or Improve.thereco
on, and who contracts cta
acts far such ptu)ewith a -
rffdorW Harmed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sm B h P C for this mason -
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
. Ow or Dee RFCFSPT N
WORINIAN COMPENSATION DECLARATION t10N - FDCFURES PER TRAP SCHOOL TAX Y_ N—
ereby affirm that I have o certificate of consent to opytneure,ora RECEIPT N
eofWorken'Compensatlonlnsurance ora certified ropythereof(Sec, GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
300,fab C.)
Policy N RECEIPT N
AS EA.SYSTEM-OVER 4(EA)C
ny BUILDING DIVISION FEES
C. C
ed copy is herebydwith the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
eddied copy is flied with the dty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
ON INSURANCE
COMPENSATION SEWER-SANTTARY STORM EA XIOFT Date Recei til
(I'Nesedion need not be camel TI lithe permit is(Drone hundred dollen
(5100)or len.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I cerBfy that In the pedormanceof thework for which this permit is issued, —
I shall not employ any person In any manner an as to became subject to the WATER SYS.IPM/TREATING
Workers'Compensation laws of California.Date PAID
PF NEW RESIDENTIAL['LMB. SQjrE. Dale Recei HI
Z 2, NOTICE TO APPLICANT-.If,after making t his Certificate of Exemption,you
should become subject t,the Workers'Compervation provisions of the Labor
TOTAL:
~ N Cede you most forthwith comply with such provisions orchis pertNt shall be
W > deemed revoked. S G FEE V
CONSTRUCTION LENDING AGENCY SEISMIC FEE ,
It, Z Thereby cork ftwhichat them isacowfmlon leading agency 7,Civ. the perform, ELECTRICFEE
� Z ance o(the workforwhkh thin permitis Wucd(Sec.3097,Civ.CJ TOTAL:
O O lander.Name PLUMBING FEE
LL F lender.Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certltythatl have read this application and state thatthe above Information
S isrom
rct.lagreetucomplywlth all city and county ordinanws cesand state laPERMIT ISSUANCE FEES PAID:
). W relatingtobulldingcoustrudlon,and hereby mthodzc representatives offhis
I. Z city toenterupon the above-mentiorsd property for Inspection purposes. ALTERORADDTOMECH. DatC Reeei tH
V — (We)agree to save,bidemNty an d keep harmlen the City of Cupertino P
agaWtbabWtin,jadgraents,cortsand expenses which mayln anywayaccrue AIR HANDLING UNIT(TO 10,000CF'M) SUBTOTAL'
a i raid Gty lnro enceofthegrantingofthlepermlt
ATR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX '
Signature of Applicant/Contractor Date E%HAI15'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2'ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO 100,000 BM Date Recei fed
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Iealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
❑ Yes N No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area AU
lity Management District] BOL-ER-COMP OHPOR100,000 BTI!) V'
Yes F❑�No
,have read the M1azardO matcdab requirements under Chapter 6.95 of BOLETI-COMP(OVQt 100,OfA BTU) q
the Gllfomla Health k Safety Code,Sections 25505,25533 and 25534.1 `Ii ✓ i ;y' 1`'90
understand thata the building does not earrenfly have a tenant,that It is myNEWROBDENTLALMECH. SQ.FT.
resperulblity,to notify the pm.f the requiremarawhlcb at be met
prior to issuance of a Certificate of Occupancy. of CBIIP,IIIt1U
cityIrl_
OwnerorauthmImdagent Data TOTAL: ISSUEDBY:
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OFFICE COPY