19698 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building PrnMct Identification - " r - - 1 PERMIT NO.
Building Address: 1�5�698
ao1. 3 JOSePit 'C ncw� L 0-r 5
wnere ante: ((�I� Phone: - A
(vsEPIa `FAILI4 ASs�• -2S9-20e CITY OF CUPERTINO-BUILDING DIVISION ^^�3_/ O -
c° o-.d°ra Na^e, ,}1( C Lie.No: APPLICATION /PERMIT d 7
.jjw� r ��Z BOLDING[ EC7RCALPLUMBINC-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lic.No: _
ELl-o C OBUILDINGPERMIT INFO
Address:
s pli.Y Wp -QTv ELECTRICPERMIT FEE
PERMITISSUANCE
LICENSED CONTR TOR'S DECLARATION
Ihereby affirm that l am licensed under provisions ofChapterg(commenc, APPLIANCES-RESIDENTIALingwitJOB D ON
It...h1.fogk.eof Dlvlslon3afthe ButlnessandPm(exionaCode,and my �
license Is In to rcc and dint. PANELS / l� / 1.1
License Claes on
tiV 14
ARCHIiE ECLARATION 201-1000AMPS
0 C7� I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
(� Licensed Professional SIG L
<� OWNBR•BUILDER DECLARATION SPEC LC
p, IherebyafRrmthat lamexempt from the Contractor's Licensrhh.�yof
forth. /
og � rogow4greason.(SMIcn7Q41S,BuainexandProfe Ions edtyor 9'D0- �YL►2l�yE
county which mclulrosa pernottocoiutruet alter,imp ve,de rmpalr
rpry anystructure prlorte its Issuance,also requires eapp mNtto ,OWpRD a
GF7 S B4 a signed statement that he b Ilmnsed ant t provtthe _
3 O ConUactorb License Lew(Chapter 9(mmnenc g W Section 7000)of Divl- SWIMMING POOL
ekm3.ftbx B.aineaeand Pmfexk, Code,rt he exem )Bvr�froorand VALUATION
Gthe Haab for the alleged exemption Anyt not Sectio !,$(I,-,by any OUTLETSSW17CHESFI%TURES g��• -
A appBanl fora permit subjects the pl"earn tivll pe f ro than r4••sa
flue hundred
wnerlof (ep. 1 NEWRESIDENTIALELECIR SQ.FI. •V STORIES TYPE CONSTRUCTION
I,as owner of the props reploy es a s as(Heir sale
N
compensation,willdolheww structure n end oroffervdfm
rl.O sets(Sec.7044,Buslnex end ( low C d4T act s Liters Law
F+;$g does not apply to on owner o, try
who it aorlmprweethereory and OCC.GROIIIs RFS.UNITS
wh.doessuchworkhlmxlfor mug,Mao a ployees,provided that such ao
improvements are not Intended oroffered forsale If,however,thebuildingor TOTAL
improyereent lesold within mayearofcomptel ion,the owner-bu llderwlll have
thILIturden of proving that he did not build or Improve for purpose ofsa4.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE.contractors to construct the projoet(Sec.7064,Busicex and I'mfexbns Code: -
Th Contme orb License Law does net apply to an owner of property who AI.TFR DRAIN 4 VENT WATER(EA)
bunds or Improves themes,andwhocontracts for such pz°je to with a
' cgIl[(+ctor(s)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE .FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reasonOUTSIDEFFAIS
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N '
• RECEIN
WORKMAN COMPENSATION DECLARATION FLYTURES PER 174M SCHOOLTAX Y N
I
hereby orkers That I have o Insurance
of consent to copy thereof
or - RECEIPT p
3800,certifate of Workers'C°mpevatlonlnsurunce wacerti(4d mpythere°l lSec. GAS EA.SYS1'Ed-11NC.4 OUTLEI5 PARK FEE Y_ N
3800,Lab CJ ,
Policy tl - RECEIPT p
cr,,-1--� GAS EA.SYSTEM-OVER 4(EA)
Com Canyredited
�^TZi�AU'V l 11U( Vs1 �IT�— - BUILDING VI510. FECS
I ICedNed copy 1.filed herebyfamished.the city •�-•�— GREASE/INDUSTRL WARE INTERCEPTOR PLANCHECK FEI(
Lo�Oli CerllfiM copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SAN,T•ARY-STORM EA 300,r1. Date RCCCI IM
(rhlssection need not be completed lithe permit b for one hundred dollars
a1I cemlem.) ' WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent em t o the person I a of the weekuser an as towhich co permit is issued,
1 shall net employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compenxeon laws of California,Date - PAID '
Z Z Applicant
RESIDENTIAL I'LMB. SQ.FT. Data RCcei [T!
Z 0 NOTICE TO APPLICAM:If,after making this Certificate of Exemption,you •�
Fah.ldbecome.bjedt.th.Worken'C.mpeiaatlonprovlslomofthe Labor TOTAL:
T Cole,you must forthwith comply with such provisiora orthis permit shall be '- BUILDING FEE rJ
W > deemed rovoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
LU C /
I hereby of irm that there b a cwatmdion lending agency forthe perform (�aELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O Lender'cName PLUMBING FEE
LL ~ lender's Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -
OW Imr11/ylhatl have read this application and statethatthe above Information
6 bmreect.Iagree tocomplywlthall city and county ordinances and gate laws PERMIT ISSUANCE / FEES PAI D:
fn relating to building construction,and hereby authorize representatives°(this
I- Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH.
(We)agree to xve,indemnify an d keep harmdem the City of Cupertino Date ReceiPtil
V
against liabilities,judgments,notes and expenseswhichmay manywayaccrus AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL: I a
shoo said City In consest it gantingofthispemnit.
`� Z Ij - AIR HANDLING UMT(OVER 10,CWCFM) CONSTRUCTION TAX
mtumot Applicant/Contrador Date V E%HAuRTHOOD(W/DucT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE t
Willtheapplies atnt or future building oFcupant store or handle hazardous HRATINGUMT(TO IDgWOBTU) Date ReceiplN
merul as defined by the Cupertino Munitlpat Code,Chaptsr9.17,and the -- /
I leaithand Safely Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTO TOTAL: zG
qYes rf No I ,
ill the applicant w fu mbuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazard...alt contandeanls as deaned by the Bay Area At,
. Qu lity Management Distrld7 BOILER-COMP OMs OR 100,000 BTU)
4Yee E❑No !!11 La
havercadthehaza usmatedalsnequtmmnnhunderChapterG95of BOILER-COMP(OVE4100,000BTU)
the Ca lifomla Health ASafety Code,Sections 25505,25533 and 25534.1
understand that if the building does not cor etly have a tenant thatitbmy NEWRESIDENTTALMECIL SQ.Fr. 4r1���, si � rIJJI]
neponsibillty to nally the occupant of the requirements vhich must be met r
prior to issuance of a Certificate of Occopancy,
Ci—tygO�F.fllo�rtinri
Owner or authorized agent
Date -TOTAL.. s� ISSUED BYL;�'(I
(/
OFFICE COPY