22004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building project Identification PFR.WT NO.
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Building Adm
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3�/fNY�DG-�d�ildlal$ ^ CITY OF CUPERTINO-BUILDINGDIVISION �S ^ S
trader.N ma: Lk.No; APPLICATION I PERMIT
I BUILDINGELECTMCALnUMBING-MECHAMCAL CATEGORY CONTROL N
Archimet/Engineer. Lac.No:
c� x
n ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcu; PERMIT ISSUANCE I��• [:1 ❑,
LICENSED CONTRACTOR'S DECLARATION L_F
I hereby affirm that l am 0censed under provisions o(Chapter9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth5ectlon 71X10) on311th,Buslrussand ProfuNonsCode,end my �s�-�
Ilcence n o aLV
License Ch �.r CO Lk.Ya
Is ifnddoffeeffect PANELS
� � ?�Date Cont L a'
ARCHITECTS DECLARATION 201-1000 AMPS
KZ I understand my plans shall be used as public records. OVER 10DO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O❑O
Fi d E Licensed Professional SIGNS ELECTRICAL
<<�6 OWNER-BUILDER DECLARATION SPECIALCI2CNT/MISC
ZF, Iherebyaflrenthat lam exempt from the Contractor's License Law for the
ooQq�y c.ufollowing mason.(Section 70315,Business and Professions Code:Any city or
Z.
Fz a ntywhichrequim.perm(ttomratmd,aller,bnpmvennW
,deh,ormpair TSP.METER OR TOLE INST.qqq� a anystructure prim to its issuance,also requlmlhe appBranlfor such perout to
file a signed statement that he as Ilcensed pursuant to the provisions of the POWER DEVICES
Communes License law(Chapter 9(commencing with Section 7000)of Divi- tall J*
SWIMMING[POOL ELECTRIC VALUATION
SOS
I'll 11th,Balcusend Profmlons Clde)orthat hehexempilhereIne,ed
Y.' the bash teethe alleged exemption. Any violation of Section 7MI-5 by any
« appllant(orapermitsubjecttheappkcanitoatlWlpensltyofn.trtercthan OUTLETSSWITCIiESFI)CIVItES
COle
five hundred dollars(%5110).
�1,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR SQ. . STORIES TYPECONSTRUCTION
C7q compensation,will do the work and the structure t east intended or offered for
$F 0 sale(Sec 70K B..Ineu and Professlma Code:The Contractors License law
S$ does not apply to an owner of property who Wilds or improves thereon,and ,OCC.CROUIP RIES.UNITS
who does such work hioaelforthrwgh his own employm,provided that such
Imprev,mentare not Intended proffered for sale.If,however,the buildingor TOTAL:
Impmvemcnt tsold w thnoneyearofcompletloMtheowner-W Oderwillhave
t rden of proving that he did not build or Improve for purpose ofule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
�I,as owner of the property,am exclusively contracting with Ilcenaed
contractors to construct the project(Sec.7014 Business and Professions Code; PERMIT ISSUANCE
tr
The Contractor's License law dm net apply to an owner of property who ALTER-DRAIN kVENT-WATER IEA)
Wilda or improves thereon, and who contrafor such plo -
jeets with a FEE SUMMARY
Tdert.)Il...d pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE OUTSIDEFITS
IJ I am exempt under See. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
Of hereby oHtrm that I have• Insurance
ate of consent to copy
theme ora RECEIPT N
3800,certifLab of Workers'Compensation luurencemacertified c.pythertnf(Sec. GAS EA SYSIEMI INCA OUTLETS PARK FEE Y N
3800,Fab C.)
Policy Y RECEGAS EA.SYSTEM-OVER d(EA) DING Of
N
Com any BUILDING DI VISION FEES
�CertiBed copy t hembyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ed
CertNed ropy t tiled with the city inspection division.
CERTIFICATE OF EXEM"]ON FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-SANITARY S[OIiM -A.MET Dale Recei t#
(Thts,ctwn need not W
COMPENSATION
permit t(or one hundred dollars
(5100)orleuJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that In employ
an person
an theworkmanner forwhiWas to b cornhis ertnit la issued,the j
I shall not employ any person In any manner m u to become subject to the WATER SYSTEM/TREATING
WorksCompensation Law.of Gll(omla.Dale � PAID
OZ Applicant NEW RESIDENTIAL PLMB.- SO.FT. , Dale Remit#
Z O NOTICETO APPLICANT-.If,after making this Certificate of Exemption,you
shwld become subject t1 the Workeri Compensation provisions of the Labor TOTAL: .l a
CCN Cade,you must forthwith comply with such provisions orthls pemdt shall be I G .�
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there t a cpm uction lending agency for the perform- ELECTRIC FEE
:3Z ance of the work for which this permit t issued!issueec.3097,Civ.C.) TOTAL: I
00 Iender.Name PLUMBING FEE
IL ~ Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW a Icutilythatl have readtht application and statethatthe above lnlormadon
ll iscorrect.Iagree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID.
relating to building construction,and hereby authorize representatives of this
U) city to enter upon the above-nantloned property for Wpectinn purposes. ALTERORADDTOMECH. ,
(We)agree to save,Indemnify an d keep harmless the City of Cu pedint, Date Receipt#
igalmt Babi tics,jad s,cmt and,.N.eswhicheayi...ywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:.
n id Ity In n e oft granting of this permit
_ AIRRANDLINGUNIT(OVER10,000CRd) CONSTRUCTION TAX
gn pp am/Contract. a Date^ D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or future buildingoowpant store or handle hazardous HEATING UNIT CTO 100,000 BTU) Y�
material as defir&d by the Cupertino Municipal Code,Chapter 9.12 and the Date Recel t#
Health and Safely Code Section 25533(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea , ri�,1 No
Wiilthe applicant.,future building occupant useequipmnt ordevices VENILA PON FAN(SINGLE RESID) ISSU CE DATE
which emit hazard...air contaminant as defined by the Bay Area Air
Quality Management District? BOILER-COMP(378P OR 100,000 BTU) '
❑ Yee g No
IUcancadlheha pus materials requirement under Chapter 6.95 of BOILER-COMP(OVQt 100,000 BTU) „aaa��yaaR �
the Califar.t HeallhkSafetyCode ,tl
,Sions25505,25S33and25534.I �R 5 J?
understand that if the building does not mrrently have a tenant,thatit a my NEW RESMENTIAL MECH. SQFT. l
respouibil0y t.ruxily the occupant of the requlrementa which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorised agent - Date ISSUED BY:
TOTAL:
OFFICE COPY
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APIs ts91
APPROVED ii II
IN ACCORDANCEWITH THE CITY 09
CUPERTINO CODES.AND ORDINANCESI 4 j BLDG. INSPECTION DEPARTMENTi
CITY OE CUPERTINQ,-"
DATE
SIGNED
This set of plans an specifications MUST
be kept on Cie job al ail times and it is un,',
lawful to Mahe ally ghanges or afteradons
on same without w itten permission from
the building Dept., Cit)"of Cupertino.
The stamping of this plan and specifications
SHALL NOl Le Lcid to pormit or to be an ��=5
approval of :ha violati m of any provisions
at eny C';v cr State Law, Z;t Z R6
Rac{{ 2 rC y
OA,If Ft{iltMp(i,ll?I:St51TH THE City OF
AND 0 R[)NANCFS �IJ�
APR 5 lg3 �D
SIGNED
- __.. .,. ... 1
This set ofp;�o a rcl sp- -'�i�icaifous-d1UST
be kept on the 'nh al ;,,, times '000- INSPECTION DEPARTMEryr
lawful to m^ko an, and it is mr CITY OF. CUP
Ocnges or afterations ERTINO.
on snrne rvilhavi r;,itten permixsion from
the huildh,f; I?et ' , r;!� r.t �t:.certirto.
The slaetpi:r ai vj ,
:ro ,-„.:; l;scfiaSNAI_I. It'd
; :;rrnit or to ha
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