19783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemlficatlon _ PLRM]TNO.
Building Add..,:
19783
ners mc: APPLICA HON SUBMI I IAL
CITY OF CUPERTINO-BUILDING DIVISION
in or'sN' APPLICATION / PERMIT O _
�.
Arc it / glneer. L
Lie.No.
BUILDINGELFf_TRICALPLUMBING-MFLHANTCAL CA BY CONTROL#'
Q� QTY ELECTRIC PERMIT FEE .BUILDING PERMIT INFO
Address: PERMITISSUTANCE SLUG EI.EUI I'LUMB MUCH
❑ ❑ ❑ Imo(
LICENSED CONTRAOR'SDECnsof ChON
the Section7Daffiren?hell ev licensed ofthe erpeseard of Chapler9(commrnc PANELAPPLIANCESRESIDENTIAL TOB DPSCRB'RON
Ingwilh Sedlon 7l#p)ol Dlvlslon3 afthe Bu.InessandProfeuloneCode,and my -
licenselsin 1 dfed. PANELS
Llan Ch Lk.q " lL-� v11.
Date hlra o Iriry .
ARCHITECTS DEC TION 20I-10DOAMPS
q�q�vv No QQC I understand my pisco ehaB be used a public rearde. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.Fr.
E:zu Licensed Professional SIGNS ELECTRICAL _
<<�< OWNER-BUILDER DECLARATION gpp-CGLCIRCUIT/MLSC `
7F, 1hereleyaflrnthat lameaempt from/he Contractor's License Law for the
0 following mason,(Section 70313,Business aM Professions Code:Any city or TEMP.MEI'Qt OR POLE INST.
countywhich requires a permit to corulrvct,alter,improve,demolish,or repair _
�sGG any stmdum prior to But Issuance,also requires the applicant for such permit to POWER DEVICES
m file a signed statement that he Is Bernard pursuant to the provisions of the
�O Contractor'.Licerue Law(Cha(Chapter with Section 7003 of Divi- VALUATION
Q 3 W B ) SWIMMING POOL ELECTRIC
��0a slon3o([he Business and Protemlens Code)orthat he Wexempttheretmmand -- - '
•.i the basis for the alleged exemption. Any Actinic.of Section 7031.5 by any
applicant for a permit subjectsthe applicant to a civil penalty of not ensure than OUILETSSWITCIiESFIXTURFS
E five hundred delta.(SM. NEW RESIDENTIAL RLECER .FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sale
compensation,wW dolhe wok and the structure W ort intended or offered for .
O. .rte(Seo 7054,B.Blnod and Professions Code:The Contractor.Lt..law
$ does nm apply to an owner of property who builds or Improves thereon,and OCC.GROIR' RFS.UNITS
Improvements
due...chworkhlnesiforthrough hisownemployees,provided that such
Improvement.are not Intended mothered forsale.If,howeveq thebullding or TOTAL:
Improvement Wield wlthinoneyearofcomplelion,the owner-bullderwill have ��i ..
tIdLIt.ede.of proving that he did tort build or Improve for purpose ofsale.). QPy. PLUMBING PERMIT FEEDZOIYE APN
U L as owner of the property,am exclusively contracting with Ilanxd PERMIT ISSUANCE
contra lam to construct the project(Sec.7014,Business and Professions Code:
The cctmMar's License Law does nm apply to an owner m property who pLTERARAIN&VEM-WATER(EA)
Wilds or Improv. thereon, and who contracts for such p(ajmA with a
olf,etear(s)licensed pummal to the Contractor'.Lt...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B h P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. ANITARY Y 'N
Owner - - Date RECEIPT'#
WORKMAN COMPENSATION DECLARATION FD(TURpg PER TRAP SQi00L TA% Y_ N
�ereby affirm that I have o lrtumte of consent to pythe m or a RECEIPT#
certificate of Workeri Compewatlon lruurance oracertifled ropy lhenro((Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK F6 Y N
3800,Isis Com', ..�y.. "��
I'o11ry M F�"^�']` /N RECEIPT#
Gm an f�1--H 7G1C?-C1fA�PCP. GAS EA.SYSTEM-OVER4(EA) -
y BUILDING Dl VISION FEES
I(Ied spy is hereby fumished.' GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
Certi(led copy I.filed with the city Inspection division.
CERTIFICATE OF E%EM PFION FROM WOR K CBS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2D OPT. DRIC RCCCI 1#
(Thi.section need nut beeomplemd It the permit W forons hundred dollars
(S1)(Worle..) ; WATERHEATERW/VFNIYELECTR ENERGY FEE Y' N
l emllfy shat in the performance of lhewmk for which this permit is issued, —
I shall And employ any person in any manner n as to became subject to the WATER SYSTEM/TREATING
Worker.Compenaatlon laws of Glllo.W. Date - PAID
licant I
Z Z NOTICE TO APPLICANT:Lt,after making this Certificate o(Fxempllon,you NEW RESIDENTIAL PLMB._SQAT.- Date `Remi W
O should bemnr•subject to the Work..'Compensation provisimuof the Labor TOTAL:
CC N Code,you moat forthwith comply with such provisions or this permit hall be - BUILDING .
W > daeread revoked. .,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d eofthe aorN. ,alar.Waamwelonld&.3 7,Clv.C.) perform- ELECTRIC FEE
7 Z ana ollhe work for which this permltWWsucd(See 309],CIv:CJ � TOTAL:
02 Lender.Name PLUMBING FEE
1L I— Lender.Adder.a - QTY. • MECHANICAL PERMIT FEE MECHANICAL FEE
O W IartlfythStlhave read this appllcalionaM statethatiheabove Information •0
1 Warred.!agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE / FEES PAID:
relating to building construction,and hereby authodee rcpensentatlyed of this
(— Z city to enter upon the above-martioned property for.inspection purposes., AILTMORADDTOMFCH. aDBTC RCC01 k#
_ (We)agree to save,Indemnify and keep harmless the City of Cupertino
sgalro abilities,pdgencracost.and expens.whichmaylnanywayaarue AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL:
P.gid City incon e o the ting thispermitAIR HANDLING UNIT(OVER 10,"CEM) CONSTRUCTION TAX
of Appbcant/Contractor t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUSMATERI L DISCLOSUR
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(M 100,000 BTU) -� DRI. Receipt#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the - „
Health and Safety Cade Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: -QQ
C3 Yea No
Will the appllca ed or tore WRetail p.at use equipment or devices VENDIATION PAN(SINGLE RESID> - ISSUANCE DATE
which credit hazardous air contaminants as defined by the Bay Area Air
Quality Management DlsMd7 BOILER-COMPOHP OR 100,000 BTU) PAID ,
4 Yes .Q No • r rAR
havercad theth& ors m ode,Sections
2555, under Chapter 6.95 of BOILER-COMP(OVER100,0000T71I 199
the Gllfornla Health&Safety Code,Sedlon.75505,25573 and 755M.I OCTunderstand that if the building dues not currently have a tenant,that It is my NEW RESIDENTIAL MECI I. SQ.FT. N4, ,
responsibility to notify the occupant of the requirements which must be met
prlorto Wsuanceofa Certlficzteof Ocapanry.
Owner or authorized agent Data -
TOTAL: ISSUED BYA•Y1
OFFICE COPY