20114 APPLICANT TO FILL IN IN WITHIN RED LINES — USE BALL POINT PEN ONLY
-- building Proed Identification PERMITNO.
Ouuding Address: /�O a� A
14,lasj yob' X773— 9aoo G 14
wnere sets: one:
OWT N 1GST at llssde CITY OF CUPERTINO-BUILDING DIVISION pA
Contra"°r'sNarm: Lfc.No: APPLICATION / PERMIT —' �� lv
(/9 w L? S C BUILDING-ELECTRICA4MUMBINO-MECHAMCAL CATEGORY CONTROL N
Archlte t/Fs19tomr, Lk.No:
S'J7Ju/-'2 '•f'C/C/'g P
G QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: /7 d ,14a,,PO S PERMITISSUANCE a 01 11LICENSED CONTRACTOR'S DECLARATION
7 hthSeciby affirm that lamllumsexi under im3ofheBuM provisions OlChapnsCodommenc. APPLIANCESRESIDENTIAL I..pE ",4ION
Ingwel,le fonforce. Divfect. otthe Buelnessand ProlesdomCode,andrcy IGFt`dw) n�",`e"'r^�{
Lienee la In toll force end c.11 PANES ss.,..//rr..��ArT�L ��.. rx�1��•a. �� jj
Date Ctam LIc.N
Date Contractor 1P5
ARCHITECTS DECLARATION 701-t000AMI'S
00 l understand my plans shall be used as public mounds. OVER ILIO AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
IU Licensed Profemlonal SICNSELECTR[CAL
j-n 6 LGL3OWNER-BUILDER DECLARATION gpECIALCpI�UIT/M15C
Zt, 5 IherebyafOrm that I am exempt from the Contractor's Llunse Law for the
(OHOwing reason.(Section 7071.5,Business and Professions Code:Any city or
KGF' countywhlch.quirma permttororatrut,alter,Improve,demoWh,orrepair �P' EEJR POLEI
Q anyeoructure prlorto its lseuance,also requlreetheappllcant foreuch perMtm � I D GES
U
Bit,a signed statement that he b Burned pursuant to the provfalora of the
3w� Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- GPOO ECCRI
I„�OS "o,the Business and Pmfewlom Code)orthat he bexemptiherefromand VALUATION
the basis for the alleged exemption. Any violation of Stolon 7031.5 by any ro/ 'I'L'`ale-
Applicant for apemotsubj is theapplkanttoa civil pe.try ofnt more Ilan OUTLETS iFSF1
flv�e tuolned delta.Mile.Lj 1,as owner of the Property, NEW RFSI ENTIAL % STOR[P9 7YI'E CONSTRUCTION
�n p party,or my employees with wage a thele woe
C
compensation,wllldothe work and thestrvturebnot intended or offered for
5 � sale(Sec.7044,Buslnevsand Prole®bta Code:The Contractors Llcenu i�w
(1,1 � does not apply to an owner of property who builds or Improves thereon,and GROUP RFS.UMTS
0. whodceseuchwork himaeBorthrough hlsown employees,provided that such C).
improvements are not intended oroffered forsale.If,however,thebullding or 11 WAT
Improvement bwld withinoneyearofcompltlorythewvner-buOderwlll love
Iden of proving that he did not build or improve for purpose ofsale I. QTY, P MBING FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with Iicensed PERMIT ONCE
ntr ors to ronetrod the projed(Sec 7044,Business and Professlorm Code:
Contndota License Law dm cat apply to an owner of property who ALTER- I
Wilde or Improve.thereon, and who comrade for such prposer with a FEE SUMMARY
-A-etoKq licensed pursuant to the Contractor.Lim.Law. BAC:K T. CE
I_l l am exempt under Sec. -n h P C for this.aeon
. RANSOwner Date DIFLOOR , . SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT
N
FDCTURES-PER TRAP SCIiOOLTAX Y N
❑f hereby affirm that)have•certificate o au coment to opy thereof
(Sa RECEIPT«
certitkab o(Worken'CompewHen Wu.nceora unified copy thereof(Sec. GAS F.A.SI,STIM,I INC4 OUTLETS PARK FEE Y N
3800,lab CJ
Policy« GAS F.A.SYSTEM-OVER 4(EA) RECEIPT N
Com any BUILDING DIVISION FEES
�Certlfted copy b filedheretumle city GREASE/INDUSTRL WASTE.INTERCEPTOR PLANCHECK FEE
1 Cenifted copy Is flied bwlth the city Inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWMSANTTARYSTORM EA XIOFF DaIC RCOCI [#
(Thlecedlon need cat becompleted If the SpermitURA b lorone hundred dollars
(1403)rnlese.) WATER I IFATERW/VENT/EIEG.I.R ENERGY FEE Y N
I unify that In the performance of thework forwhich this permit is issued, .—
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATTNG
Workeri Compensatlonlawwf Callfornta.Date PAID
O Z Applicant - Date Receipt
Z O NOTICE TO APPLICANT.If,after making this Cerofficale of Exemplbnyou NEW RESIDENTIAL PLUS, SQFr.
should become sublet to the Workers''Compemation pmoi.iov of the Labor TOTAL:
. N Coda you moat forthwith comply with such provisions;orthls permit shall be
> deemed revoked. N JL
aCONSTRUCTION LENDING AGENCY SEISMIC FEE 5-10
I hereby affirm that there h a cnmtroctlon lending agency for the perform- ELECTRIC FEE
Z ance of the werkfor which thlspermit b Wood(Sec.3097,CIv.C.) TOTAL:
O O Lander.Name - PLUMBING FEE
LL I— tander.Address QTY. MECHANICAL PERMIT FEE
bMECHANICAL FEE
O W I certlfythat l have read thhappliettionand statethattheabove Information
burned.I agree to urnplywith all city and county oNlnancesand elate laws PERMITLSSUANCE FEES PAID:
a relating tobullding coratrudlon,and Wrebyauthul.repusenlativeaof this
f-. N toy toenteru on the abovcmentloned property for ins, I .purposes. ALTERORADDTO MUCH.
Z (We) a to ve,Indemnify an d keep harmless the City Of Cupertino Date Reeei f#
V again ab.7111 ea
a muivMchmay I...y.yAmmA AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
ago al y In roneeq� q an g of this permit.
O AIR HANDLING UNIT(OVER 10000 CFM) CONSTRUCTION TAX
Signature of Appikant/Cont rn Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATARDOUS MATERIALS DISCLOSURE
Wllltheappil nt orfutum building ocev pant store or handle hazardous HEATINGUMT(TO100,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand SafetyCede Ion 75532(a)7 HEATING UNIT 100,000 BTU) TOTAL: 4
❑ Yea No
Will the applicant or lure building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISS DATE
which emit hazardous air contaminants as defined by the Bay Area Air �.�/( s
Quality Management Distnet? BOILER-COMP DHPOR 100,000 BTU)
Yet �`I
have read teeth&Safety
Code,Se tioW25505, 5533underAnd 25534.
of BOILER-COMP(DVER l00,gp BTU) (�~ •7
the
ersta dt Health bSafety Code,Set1omntly h ve atenad,that 1
underslandt fthe fy the ccupar.nm currently mens which
that ltbmy NEW RESIDENTIAL MECFi. SQ.FT.
ropy ityto tifytheottvpanto menta which=at bemet City of�l((1 N
Arlo Lssua ofa Certl4lcal c c/ ,t("
Her or authorized agent / Darrt,(
TOTAL: ISSUED BY:
OFFICE COPY