22016 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Holding project Identification PERMTNO.
Building Address:
B /'L^O a3 6
o a ere r , GG I von
nen are: ane:
/; 0 Z5S-bps CITY OF CUPERTINO.BUILDING DIVISION D
°"read&.Name: pLI=.Na: APPLICATION / PERMIT
G =9>3 C%Z ms's BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CO .N
_ Architect/Engler. L No:- lt,
C S/ � � '� r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naa ( rERwrlssuANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby afftrmthat l Am licensed under provWonsofChapter 9(commen APPLIANCES.RESIDENTIAL JOB DESCRIPTION
Ingwlth5ect1on7000)of Dlvislon3ofthe Buslnes.and ProfessionsCedewd my
license le i"full fora and affect. PANELS Pbicense Chm LION 38Z ,
DateContrector
ARCHITECTS DECLARATION 201-1(DO AMPS ICJ
reO Zp I Me ad ionsshall be usedm�qucmoni. OVER IODO AM SQ.FT.FLOOR AREA S/SQ.FT.
E (/ Licensed Profemlonal SICNS D '
OWNER-BOLDER DECLARATION - ✓ L
Z1., 7a Ilumby.M.that l am exempt from the Contractors License law fathe SPECIAL C
OR-
following mum.(Section 7031.5,Business and Professions Code:My city or ^
r .. county which rtquim a permit to constuct,alter,Improve,demolish,orrepalr TFMP.M EI .Kl
O MA TE
anyAtucturepdortolbhuancgalw requ pursuant
revisions of t e POWER DEV[ _
MA a signed statement that he t ganged(commencing
l to the provisions o! the as 7
µ Contactors License Law(Chapter9(ammentlngw11bSection 7000)ofDlvl-
HaOS alon3o(lhe Buelneu andlProlemlons Code)orthNhebexempt lherefromand SWIMMING BLE VA ATION
the basis for the alleged exemption. Any violation of Section 70315 by any n D
QOM
applicant for a permit subjects the a ppllcant to a civil penalty of not more than OUTLETSSWI7CES d[ D
five hundred dollars($SM. NEW RESIDENTIALE TR SQ.Ff, STONI TYPE CONSTRUCTION
7 1,as owner of the property,or my employees with wages as their sole
� < compenmdon,willdothewoikandthestmu mbnot Wended or offered for
x O sole(Sec.7061,Bu.bom and Proximate.Code:The Contractors Llama Taw
$ does not apply to an owner of pmpemty who builds or Improves thereon,andOCC.GROl11P RES,UMTS
whodoes suchwarkhim Ifo throughhlsownempinymsprovldedthatsuch
improvements are not intended oroffered for sale.If,however,thebulMingor TOTAL: 5-bp
Improvement Lswldwithin om rarofcomple WR the owner-W Bd erwill heve
'th5kmrden of perving that he did not build or improve,for purpose of role.). QTy. PLUMBING PERMIT FEE pD70NE APN
U Las owner of the property,am exclusively mntraoing with licensed PERMIT ISSUANCE _DD
contadors to construct the project(Sec 7064,Bovines and Professions Code: '
The Contractors Limme Law does not apply to an owner of property who AL MIT ISSUANCE
k VENT-WATER ffN
builds or Improves thereon, and who contrera for such projeN with a
cgp4lctor(s)Bernard pursuant to the Contractor's License Law. RACK FLOW PROTTCT.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for this reason
lee n[Maint,prre
DRAINS FLOOR RODE,AREA,CONTI. SANITARY Y_ N_
Owner Date RECEIT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
®I hereby affirm that I have a certificate of consent to self-insure,ora _ RFGEIrf N
ceMflale o(Worken'Compensatlan Wurenceaaartlfled copylhereo((Sec. GAS PA.SYSTEM-1 WCAO11TLETS PARK FIE Y N
._ Pull Lab C. O.f RECEIPT
Pull a NUG x'D O /L�®OrF GAS EA.SYSTPM-OVER 4 IRA)
Com semi ad m]/ cher L• BUILDING DIVISION FEES
�Certl ed copy b hereby miahed. GREASE/INDUMRL WASTE INTERCEPTOR PLANCHECK FEE
®Certified copy bfiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE-ASE TRAP PAID�� -(D
COMPENSATION INSURANCE SEWER-SANITARY STDRM EA 2d14T Date RCCCI [M
(This section need not becompleted If the permit b torose hundred dollar
(Sloalmiem') WATER HEATER W/VENT/ELBCTR ENERGY FEE Y N
I certify that in the performance of thework forwhlch this permit is Issued,
I shall out employ Any person In any manner An As to become subject to the WATER SYSTEM/TREATINGWorkare Compensation Lawsof Callfomb. Date PAID
ZZ Applicant rkNEWRESIDENDALPLMB. SOFT. Date Recei Ile
O NOTICE TO APPLICANT.If,after making this Certificate of FxempWltoo,you
should become subject to the Woars'Compensation provblonsafthe Labor TOTAL:
N Code,you resat forthwith comply with such provisions or this permit&hall be BUILDING O
W > deemed revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebya(grm that there b a conslmb Issued
lending agency for the perform TOTAL' ELECTRIC FEE
Z an a ofthe work forwhlch this permit ued(Sec 3097,Civ.C3
U O I<nderme'e NaPLUMBING FEE
LL ~ Lender.Addte.f - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlfythatlhave read this appli=..nd statethat theabove Information 721. 6
C Iswrrect.l agree to comply with all cityand cruntyardlnan=esand state laws ' PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby authorize repumentallvn of this
F Z city to enter upon the above-mentioned property for WpeRbn purposes. ALTERORADDTOMECH. Daft RCCeI tN
_ (We)agree to save,indemnify an d krep baroness the City of Cupertino
Against liabilities,j:dgmenb,watsand expenses which ma In anywayaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL'
against zald ity in cousequenaof the granting of,0 Pe B. CONSTRUCTION TAX '
AIR HANDLING UNIT(OVER 10•WOCPM)
Signatureof Applicant/Applicant/Contractor Date EXHAUST HOOD CONSTRUCTION TAX PAID:
ct
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 Bn1) Date Recei t»
material as defined by the Cupertino Munldpal Cade,Chapter 9.1$And the
Health and Safety Cade Section 2S532(a)? ( HEAnNG UNIT(OVER100,000 BTU) L� TOTAL:
��''77 Yea ,La.�,No
YVWthe eppliart or fuure building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as aefimd by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR t00LDW BTO
Yes I❑No nr
have read the hoz Qus materials requlremenb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Dbt ��
the Wlifornb Health A Sat Code,Sect ions 25505,75533 and 75534.] b
understand that if the building does not comedy have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
Edortot to notify I.m.foccupartaftpa requireme swhich moat be met a M5
psponsi 9 once otiy the ateof Oof thenq. �f
ner ar authodzaM agent Date ISSIRiD
Tnrnc
OFFICE COPY