20915 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ed id.wi(latlun PF}LwTNO.
Bvlldln Add o 20915
rare one IN I LDATF
CITY OF CUPERTNO-BUILDING DIVISION A
rets aN'rre: CZ !p .N APPLICATION /PERMIT
(` BUILDINGS].ECIRICALI'LIIMBINGMECHANICAI. CA'IH'AAY CONTROLArddt Esglraert IJc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. I'FRh9TIS5UANIX ❑ ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under Immidona of Chapter 9(reanmenc APP11ANC I"RFS]D L JOB DESCRB N ��
tngwlth Sectbn7009)af Dlvtelon3ofthe BuM..dProfenbnaC ,and my
linea b in tub fyryx and e.1 �� / I'ANQS /} ,a .
Datelec �� Lk.Y `5 O
Date Contractor f/C
ARCHITECTS DECLARATION
NO
ZO IuMcntaMmypUmehaDb u,ednpubhcremrdi OVER1000 SQ.FT.FLOOR AREA S/9Q.FT.
NYIEu Lkensed Professional S G AL
G r�a,Fd
OWNER-BUILDER o DECLARATION SPEICIA U17
7 t'ma Iherebya/firmthat ctia,7 exempt fro ossa Contractor's License Code Law fat he
followinit hre "q irecllon7 ittocoelnev,rd 1,impr Ve, Code:Mytlty it
F�^ muntywhkh requbeaperMttommlroct,alter,impmve,dermLLsh,or repair I TEMP.NOVTR O NSf.
S anystromare priortoibsu
isance,abe
o requlrthe.pplicea!¢such permit to
P O file a signed satemeM the he la B¢nsed purvnant to the pmvlebv of the
[Wj µ� Contntor'a Llcenae Law(Chapter 9(commencing with Section 7(UD)of Divl- NG LEI.E
F IS0 aia.3 ofth.Rusineae and PrafeaebnaCode)orthat he b esempt therefromeal VALUATION
3 �p a the base for the alleged e.eenptbn. Any violation of Section 70115 by any
p� applicant fora permitsubjM,the applicant to a civil penalty of not mon than SWITC Y .
fix,�ndred dollars 35(fr.
LJ 1,a ower of the property,or my employees with wage as tlelr sok RIDDFNTI e"Q'FT' STORIES TYPECONSIRLCTION
mmpevatlm,will dothe work and theatroctun b not Intended or offered for
Cl sak l5ec 7W Buebea ant Profesnloro Cod,..The Com"dora Lloo.f aw
s$ don not apply to an owner of property who bunds or Improve thereon,and OCC.GROUP RFS.UNf15
who do¢suchwork himself.,through hlaownemployee,provided thatsuch
Imprwemew are ret intended oro/fened/male.IS however,the W Tiding¢ TOTAL
Improvementbsddwtthln M did nobuild rimthee forpurposerwWhave
t La.owme ofig thrtheddrwt b exchadmproverarpurpmentneas QTY. PLUMBING PERMIT FEE FLOOD ZONE AM
Lj L on Done of the Property,,m essK Bony contracting with.c limed
mntrut¢s to mratroct the pmjea(Sec 70a,Bu.inem and liofe®bna Code: I'FRMIf ISSUANCE
The COotnctore License Taw dm Mt apply to an owner of property who ALTER-DRAIN 4 VENT WATER(EA)W lids or Improve thereon,and who mMram for sua pto)ecta with a
n7attact¢(0humsed pursuant to the Contractors License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B k P C for thio reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owns Dato RECEIPT
WORK MAN COMPENSATION DECLARATION FTX.)URFS PER TRAP SCIdO0L TAX Y_ N
❑I hereby affirm that I have,certificate of consent m xlf-Tort,¢a ' RDZEIT ,Y
¢00,Lab of Workm'Compenaatlon lrneuran¢ma cenllkd mPY thenol0lec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Polk Iib CJ
Courcy Y GAS M.SYSTEMOVER i(EM, - RJECEP�Y
Y BUILDING DIVISION FEES
Certified copy b hercbytume cityIeei. CREASE/AIDUSTR,WASTE INTFRCFPTLIR PLANCHECIC FEE
❑Cenined copy b filed with the city Inspection didsion.
CERTIFICATE OF ID(EMPFION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SLIVER-SANITARYSTORM EA IO�p Date Remit#
Rhin section need neat M carnplcted lithe pertNl b(m on hundred dollen
(5100)ofy,th WATER HEATER W/VENT/ELEErR ENERGY FEE Y N
1¢not that in employ
an person
nce In an me oak so as t oh this bacomp rmit subjee bo the
I stall not employ any Lawn b any manner n a to become subject to the WATER SYSTEM/TRFATING
O Applicant
Work¢n'Compeaatbn Vw.of California.Date PAID
PP NEW RESIDENTIAL PLI(B. 9QFp. Date Recel t#
Z z NOTICE TO APPLICANT.If,afle making the Certificate of Exemption,you
HN shoulde becomsubject to the Worker:Compamatbn provbbns of the lrbor TOTAL
cc _ Cade,youmntfwthwkhmmply Mthsuchprovbbroorthbpermltahallbe
] deemed revoked. BUILDING FEE
W p CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyafl hat then b a mnatmetic,lending agency for the perform Trn.nL, ELECTRIC FEE
Z aceof the work(or which this permit b hued bee 3097,Ch.C)
(� O Lender's Name PLUMBBVC FEE
LL Lender.Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtffy thatl have mad thbappB¢tbn and areethat the above Information
4 bmrnct.lagreetocomplyw aU, yaMd ntyordbunoeandstatelawe PERMIT ISSUANCE
} N relating tobslldleg mratmctlon,and hereby authorla,rcpresenatNn ofthb
F Z city to enter upon the above-mentbrad property for Inspection purposes. ALTERORADDTOMECH.
(We),gree to save,indemnify in If keep hernem the City of Cu Fenton Date eccl [#
V egalnat WbWties,Judgments,malsaed expense which may In wayeeme AIR HANDLING UNIT(p010,000 CFM) SUB TAL:
against said City in mnaequ.ea of the gra re jog a this permit. — 4
AIR HANDLING UNIT(OVER 14moCE}M) CONSTRUCTION TAX
Signature of Applicant/Contractor Date FrruUST HOOD(W/DUCT) CONSTRUCTION TAX PAID.
HAZAR DDUS MATERIALS DISCLOSURE
WllltheepplloMafuture bu0ding oaNpant store or handle haaaNws HFATINGUMTC10100,0DOBTTn Date RCCCi t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code Section 25532(A)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYe, MN
ill thea pplicant or future building occupant use equipment or dovice VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit herardeas air mntenlr nts as defined by the Bay Area Nr
CialNy Sia.gerrcM DW riet7 BOE.ER-COMP QHPOR 100,0110 BTV) a"a;�_
` Y. N
have read the arise requlrtmenaander Chapter6.95af BORER-COMP(OVER 100,000 BTI!) � 1
theGBlomlali Sats ode,Smbna25505,75533 and 255.11.1 1�V L/ � .�. 1990
and t ebu net aNrrcntly luve,tenan4 that it"s my
NEW RESIDENTIAL MEIN. SQFF
Po M net of the=11nementa whkh rust be met
P to ace arOcvrpancy. C YFf,.Jnjrtjqr)
nermsuth agent Qate I Y:
TOTAL:
• OFFICE COPY