20184 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identificationas 1� ^C2 rk i r $ PERMITNO.
Battdinq-110o c s �� v 1� o. VKL Y �q�,� . 20184
Owner'sName:
—L J -�/j-C.� QID ane CITY OF CUPERTINO-BUILDING DIVISION �y�
anhactor'e Name: LIc-No, APPLICATION I PERMIT `—'''� l
Nimbi, 0.2 S C d-�lt A BURAINGELECTRICAI-PLUMBINGMECHAMCAL CATEGORY CONTROL)
AmhttM/Engineer. LIv No:
- /1 ,I QTY ELECTRIC PERMIT FE�Es BUILDING PERMIT INFO
Addresx� JLV- e-; K-7- CIS112— PERMITISSUANCE �taf.!
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCESRESIDENfIA JOB DESCRIPHON
tngwith Section7000)of Divielon3ofthe BustnessandPmimionsCede,and my
likens Is In full force and Cleat. PANELS 1Lkam
Date Clan O Lica
Date_ Contract
ARCHITECT'S )ECLARA ION 211-10MAMPS
O ZpG I understand my plana shall be used n public records. OVER1IXp SQ.FT.FLOOR AREA $/SQ.FT.
k
Cd,
U Licensed Pmfenional SIGNSELECTRIC
<< OWNER-BUILDER DECLARATION *S7W%MWL
Z.p�4 I hereby affirm that l am exempt fmmthe Contractor's License law for the
OZti followingrenon.CScation7031.5,Businessand Professions Code:Anytlty or N
F4 county which requires a permitta construct,alter,improve,demollshorrepalranystmmmpriortoibbwanae,alsorquimlheappBantforsuchpermitta file a signed statement that he is licensed pursuant to the provlmas of theContractor's License Taw(Chapter 9(commencing with Section 7000)of Divi- VALUATION
sthealanexempton. Anyiolatinofexempt therefrom and RIC
the bash for the alleged sects th a p Any t tolalon of Section not m re any
aPPllantfora permit sub(ects the applicant ton tivll penaltyotnot morethan TURFS
five hundred dollars(ISM. NEWRESIDENDALELECTRFf.
7�n F1 1,as owner of the property,or my employees with wages as their sole SQ STORIES TYPECONSIRUCTION
compensation,willciothe work.and thestructure is not intended or offered for Z 1 75 L-VA 9 Q J i a
O sale(Sm 70K Businessand Profeadona Code:The ContractoesUceme Law
does not apply to an owner of property who builds or improves thereon,and O� OCC.CROUP RFS.UNITS
who doeseuch work hlmael(or[hrwgh hleown employees,pmvWed that such
improvementeare not Intended onset(ered forsale.If,however,lhebullding or TOTAL: v(�
improvement hsold withlnoneyearofcompidion,theowner-bullderwili have
tlAjZurden of proving that he did not build or Improve for purpose of ads.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the Property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the pmject(Sec 7014,Business and Professiom Code:
The Contractor's Linens Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
build@ or improves thereon, and who contracts for such Projects with a
cryglactor(@)licensed pursuant to the Contractors License Law. BACK FTAWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,CON I, SANITARY Y N
Owner Date RECEIPT R
WORKMAN COMPENSATION DECLARATION MTURES.PER TRAP SCHOOLTAX Y N
I hereby affirm that I have a omi(Wte of consent to aelf-inwre,ora RECDI'T M
00 ab C.)
0 too(Workers'CompemaRanlnaurana oracertlfkd copytherea((Sec. GAS ST
EA.SYEM-1 INCA OUTLETS PARKFEE Y N
Policy : T- 90SL319 DING DTP
Com env ?(4,)0 «Labs rnr n.e... t. .s� GAS FA.SYSIEM-0VERaIRA) BUILDING DIVISION FEES
�CertlOed copy is hereby-Mth thshed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�ertlfled copy V filed�Mth the edY inspection division. ,
CERTIFICATE OF EXEMPTION FROM WO R KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SA EA 2l�1' Date Rears t#
(This section need nal)completed If the perrrdt V forms hundred dollen
(f100)arlen.) WATER HEATER W/VENT/EI.ECTR - ENERGYFEE Y N
I certifylhat In the performance of the work forwhich this permit Is issued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSIFAf/TRGTINC
Worked Compsvatioo lawsof California. Data PAID
O Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQFT. Date RCcel k#
Z D NOTICEco become
t tothe,after maWompong ut[onCertifkneo(ons oft the
Cade,shoulbe mus subFtto the Work en'such pnwisinprovlebmomits Labor TOTAL:
LUN deemed youmustcomply with such provlsWmorrhbpenNt shall) NG,
CL `> darned revoked, r
CL FEE
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflorkNt)ttherela tIsisud(Sec. ,Civ.C.)
ELECTRIC FEE
� Z ane of the work(or whkhthln permitb blued(Sec.3097,C1v.C.) TOTAL: a�
O O
Lenders Na ma PLUMBING FEE
LL Lendreaaddrea. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irealfythatl)vemadthlsapphationand Catethattheabovetnfomution
1 Is correct.I agmto comply with all dlyand cuttyordinances and Nate laws PERMTTISSUANCE FEES PAID:
>. N miatingtobulldingmmtmCion,and)mbyauthorlaempmwntativesamthle
Z adtytoenterupon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to wve,indemnify an d keep harmless the City of Cu pertlrw Date Receipt#
V against liabilities,judgments, expenses which my In anywayattmae AIR HA DUNG UNIT(TO I%=CFM) SUBTOTAL'
against said City In consequenceof the granting of this permit.
AIR IiANDWNC UNCI(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contranor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date RCcel [#
material as dell red by the Cupertino Munidpal Code,Chapter 9.12,and the -
HealthandSafetyCodeSedion25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Vx/
❑Yes No
WII11he Spplicanl ar Nre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which omit hazardous air contaminants as defined by the Bay Area Air
u�aflity.read the hazerdManagement District? BOILER-COMP DHP OR 100,000 BTU)
I ousomaterials requirements under Cha iter 6.95 of RORER-COMP(OVLR 100,000 BTU) P-MD
ave
the California Health k SafetyCode,Sections 25505,25.533 and 25534.I
understand that if the building does nor currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the oceupant of the requirements which most be mel
prior to Issuance of a Ceaiflcate of Occupancy.
Owner or aulhoazed agent Data ISSUE
Dg�'
TOTAL:
OFFICE COPY