20091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulldtn`g Addmmx::'� 4,, { 1 1f[� ^'/11�//''� 20091
one: A
IJ C2¢ CITY OF CUPERTINO-BUILDING DIVISION �"—�—ry�
C°"ta orNNam: Lie.No, APPLICATION /PERMIT C-ll
Tae o� ean5�, 3l9tR
ArthlteR/Engineer. 9U[LDINGTRI
ELECCALPLUMBING-MFLIiAMCAL CATEGORY CONTROL
Lic.No: p
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: Q O /l U V PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL
ingwith SeRlon7000)of Division 3°1fthd Businessand ProfessimsCode,anJOB DESCRI'110N
d my JO
I.icen IC n fu rce endc.leffect. �1 , PANELS
Date Contraci&. L P U n SIM TO ZDO AMPS
ARCHITECTS DECLARATION 201-10DOAM,PS
Rob 7 I understand my plans shall be used as public records. OVERIODOAMIS SQ.FT.FLOOR AREA $/SQ.FT.
L60�y
Licensed Professional SIGNS ELECTRICAL
G G�° OWNER-BUILDER DECLARATION SPECIALCItCUIT/MISC
I hereb .(Inco that lam exemptfrom the Contractor's License Law for the
'Z Za Y O_ =ntyreason.(Section 7031.5,Business Professions Code: h, city or
OZF.� following y ty TEMP.METER OR POLE INST.
countrounum Prior tesa permrdealsurrouireatheaprovgdemofish,ormit to
any attuaure paler eats that
he is lice requpursua t to the for such provisions of it a POWER DEVICES
O 0.S floe a signed statement that he b licensed pursuant to the provisions of the
3O� Contractors License Law(Cha)ater9(commencing with 5Cl110e 7000)of Divi- SWIMMING POOL ELECTRIC
1on3ofthe Businessend Profeselose Code)orthat he is exempt therefromand VALUATION
~ SR the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit sub' theapplicant to a cvll 1 of morethan OUTLETSSWITCHESFIXTURES
❑A fvP Pe 1�' penalty .
R(i flue hundred dollen(ASW). NEW RE4DENT[AL ELECTR
I,as owner of the property,or my employees with wages as their sole e"Q.FT' STORIES TYPE CONSTRUCTION
f,7¢ compensation,will clothe work andthesmuture Is not intended or offered for
^^�y M❑ sale 0x c.7044,Buslnew and Professions Code:The Contractors Llceme Law
2R does not apply to an owner of property who builds or improves thereonandRFS.UNITS
who doessuch work himself orthrough his own employees,provided thatsuch -00C GROUP
impmvemumaa are not Intended proffered for sale.IL however,thebuilding or TOTAL:
improvement is sold within oneyearofcomplelion,the owner-buticierwlll have
t1glZurden of proving that M did notwuanrimproveforpurposeofsale.). QTy, 'PLUMBING PERMIT FEE H.00D70NE nrN
L as owner of the property,am exclusively contracting with licensed PERMIT LSSUANCE
contractors to construct the project(Sec 70K Business and Professions Code:
The Contractor's License Law does am apply to an owner of property who ALTER-DRA W k VENT-WATER(lieu
Wilds or Improves thereon,and who contracts for such pk0jecn with a
cgDlfadoKa)Iicensedpunuanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION pIXTUgES pF3i TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that I have o cetiiRate of consent to y thereof
(S . `
3800Leo(Workers'Compewtlonlrou�r oacerti(kd copythdteof(Sec. RECEI'fN
33tX�bC.)n N-�,L-.�IrR�N.�' ail! � �! GAS EA.SYSTFM-1 WC.40UTLEl5 PARK FEE Y N
R]�' �U sr I)j S D RECEITN
Com env ! ✓ ra II n. t GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy Is herebyfurnished.the cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Rhlssection need not becompleted Rthe permit bforonehundreddollars SEWER-SANITARY-STORM EA.200FT. Date Recet tit
($100)orfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
[certify that H the person In any
m work for o towhichb co permit is Weed,
I shall not employ any person In any manner so v to became subject to the
Workers Compensation laws of California.lifofloia.Date WqT�''-YSITA4/1RC/`nNG PAID
O Z ApplicantZ Q NOTICE TO APPLICANT.If,after making this Certificate of Exempt ion,you NEW RESIDENTIAL PLMB. SQ.FI Date Recei tN
F
Code,
asforth mthe ply with
provtbnprovbis permit s Lebon TOTAL:
WW Code,you=at forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILDING ELE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afirmthat there b a mmtructi°n lending agency for the perform rs>.N ELECTRIC FEE
Z anisef the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL: G C..UU
U O ).enders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE
O W Icer lythat l havemad this appliationand statethat theabovetnfornud MECHANICAL TEE
1 booed.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>- W relating to building construction,and hereby autho ae representatives ofthis
f-. Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We).agree to save,indemnity an d keep harmless the City of Cupertino Date Reteiput
Zairst liabilities,judgments,cobtsand expenses which may In anywayamrue AIR HANDLING UNIT(TO II,000 CFM)
a Wt said CityIn consequence of the granting of this permit. SUBTOTAL:
AIR HANDUNG UNIT(OVER t0,Do0CF:M) CONSTRUCTION TAX
Signature of Applicant/Contractor - Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheappBant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0°08M
materialasdefined by the Cupertino Municipal Code,Chapter 9.12,and the _ Da Reeei tq
Ilalthand Safety Codr Se n25532(a)7 HEATING UNIT IW,OW BTU) TOTAL: �Cy
❑Yes pe
Will the a ppiiant or tore building oampant use equlpment or d evicts VENTILATION FAN(SINGLE RESID) r{�1R 955UAN DATE
which drat hamrdousair cont nanbas defined by the Bay Area Air s, U
Qu?YManagement Dlt BOILER-COMPOII'OR too,"BTU)
TTI Yrs No ^.�
have read Healthe h
a pus materials tions 2mentsunder Chapter G95 of BOILER-COMP(OVQt1W,0000TU) wC �Bp �
the California Health A Safety Code,Sections 25505,2$533 and 25534.I
undentandthatifthe bulldingdoesnaamntlyhaveatenanpthatitbmy NEW RESIDENTIAL MECH. SQ.Fi
responsibility to notify the occupant of the requirements which m'ust be met
prior ua no,ofa Al fiat¢of Occupancy. Lf D
Owner or authorned agent
TOTAL: ISSUED BY: VO`G;��M1 V-1s-+�+`-c+\
OFFICE COPY