20445 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES;— USE BALL POINT PEN ONLY
Building Project Identification
yPERMITNO.•
UuIlding A716di�S kir'cawio baro, .. 20445
pConpor'sName-
&r Z47y/2 CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT (/
Q /O BUILDING-ELECTRICA1.Pf.UMBINC-MFGFIAMCAL CATEGORY CONTROL N -
Archltett/Engineer. Lic.No:
2,, QTY ELECTRIC PER �FEe . BUILDING PERMIT INFO
-
Address:lvz "b ra 3 cru — PERMITISSUANCE". ,�D ,� e ® ❑
LICENSED CONTRACTOR'S Hb--CCLARATION
I hereby affirm that lam Remaed under provisions of Chapter 9(commmc APPUANCESRESIDENIIAL JOB DESCRIPTION
IngwlthSeafon 700D)Of Dlvislon3o/theBusln.sand PmfesslonsCode,and my.
license Is In full fa and effect. aZ PANELS i`
Lim ,yvn LIeN A3 .a���a S
Date nor �xd/I( 701-IOW Iffi il—!1 I I,-`
ARCHITECTS DECLABATIO
I undentand my Flare shall he used ed as public records. DYER 1 SQ.FT.FLOOR AREA S/SQ.Fr.
O r-
6 LI...d Professional SIGNS ELEC
6� OWNER-BUILDER DECLARATION SPECIAL CIIZ;�T/hj
z� 7 harebyaffirmthat Iamexempt from the Contractors Uren.Law for the
O .. following reason.(Section 70315,Business and Professions Code:Any city or M I T '
rES county which requlresa permit to construct,eller,Improve,demolbh,orrepalr -
q anyotmdurepriorwiteIssuance,alsorequimsiheappllnntforsuchperndtto
S Ole a signed statement that he is licensed pursuant to the provisions of the PO
30� Contractor's License Law(Chapter 9(mmmerelog with Section 7000)of Divi- S POOLELECTRIC'
aJoe 3ofthe Buslness..d Profeashma Code)orthat he O isexem therefromand VALUATIOpj the bats for the alleged exemption. Any violation of Section 70315 by any •) OUTLETSSWITCHE&FIXTURES / o So k A
app.nlfora perrmteubjeMlheappllcammativil penaltyo/not nnrethan •'� ! a D .
A
live hundred as
rowner of the
SQ.Fr, STORIES rMECONSD0ICTION
NEW RESIDENI7AI,ELFATR
�n ❑1,sa owner of the Property,or my employe.with wages thele sole
rot.Cnc.tton,70K will Rusin ss andthe week,and the fmalon,Code:
b race]Mended or iceres,d for
Law -
O sae(Sec 7064,to Business end f onpert u Code The Contractor's Llre.e Law
1 S� don not
suchwrk owner ofpreugh who Wilds orImproveseon,and
that
OCC.CROUP RES.UNITS
who does euchworkhimself orthrough his own employees,provided that such
_ Improvement...not Intended or.ffemd for sale.If,hmvever,thebulldingor TOTAL: ,OQ ,
impnevementisa.Id within°neyearofcompletlon,the owner-builderwillhave - a
the burden of provingthat he did not build orlmprove for purpossofukJ. QTY. '.PLUMBING.PERMIT .FEE FLOOD LANE APN
F f L an owner of the property,am exclusively contracting with Burned PERMIT ISSUANCE
contractors to construct the project(Sm 7066,Business and Profe.i us Code: �• D D'
'rhe Contractor's License Law does not apply to an owner of property who
Wilds or Improv.thereon,and who comratts for such pksb Sowith a ALTER-DRAIN k VFNT.WATER(EM
contractor(.)licensed pursuant to the C..1me e.Limas Law. FEE SUMMARY
01 am exempt under Sec IS k P C for this m.a BACKFLOW PROTECT.DEVICEOUTSIDE FEES
Owner Date
DRAINS-FL AOIR ROOF,AREA,GOND: SANITARY Y N
RECEl0
_" WORKMAN COMPENSATION DECLARATION FDIURFS PER TRAP �� SCHOOL TAX Y N_
�j here affirm that 1 have a nrtlflute of consent to self-insure,or a RECEIPT N
380art0,Lab
of Workera'Compe.atlonl uranin ora mrtl(Ied copytheomf&c. CAS F SYSIE1,44 INCAOUTLETS PARKFER Y N '
3BW,IabC.) p36s��
Poliry p _Tn� - RECEIPT M
F CAS EA.SYSTEM-0OVER
Cam BUILDING DI VISION FE ES
ertlfledcopy a by r-mit eh�'—j—• GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
enifled'mpy V tiled with the city inspection division,
CERTIFICATE OF EXEM PT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.7WFT. Dale Retnf tic
(I'hlssectlon need not h completed If the pemdt V forcers hundred dollars
(fl W)erfieth) WATER HFATUR W/VENT/ELMTR ENERGY FEE Y N
I.not that So the persmammoy a weekneer so m to b co permit issubjec issued,
'I shall not employ any person In any manner at as m become subject to the WATERSYSTEM/TREATING
Worlican Compenaatlon Lawn of Califomh, Date PAID
—
0 Z Applic.NOTICnt - NEW RESIDENTIAL PLME SQFr. Date Recei tN
Z 0 - NO3lCETOAI'PbICt to
cher rs'Co per attonprovisions
reofons ofthe Labor
F shde,youould =at forthwith
co ply wit'Comperuason porthio.rmit&Labbe TOTAL:
a. N dunned uvoked.nhwilh comply with euchprovlelom settee permit shallbe -BUILDING , 0
W ] deemed revoked.- � ,.
d FS CONSTRUCTION LENDING AGENCY SEISMIC FEE kndo
I hemby affirm that there is.consWtlion lending agency far the perform- TOTAL: �1 p ELECTRIC FEE - 3.0
� once of which]tele permit is (&c.3097,CIV.CJ yG0—
V O Lender'.Name - PLUMBING FEE ze).00
u. F Lendce.Addm. QTY. MECHANICAL PERMIT '
O W Imnlfythat l havereadthisappOntlonand date that theahove Information MECHANICALFEE
IL burred.l agree to comply with all city and county ordinances and state laws IT ISSUANCE FEES PAID:
>. relating tobuilding construction,and hereby authorize representativesof this
tltyto enterupon the above-mentioned property for inspection purposes. AL ORADDTOMECH. DatC Retei IN
(We)age.to save,Indemnify..d keep banned;the City o/Cupertino
IV agahurllabllltic pcigroms,mg.and expenses which may Inany way scene AIR FIA UNOUNITIT010,000CFM) SUBTOTAL: •3
agar 1 In mnyaF—4 of grant ng o/thl.pe
l.�J ZZ MR HA NNJNG MIT(OVER 1D,WBCF. CONSTRUCTION TAX
grw rcof AppUOant/Contra to . Date EXHAUSTH (W/DUCT) - CONSTRUCTION.TAX PAID:
HAZARDO ATERIALS DISCLOSURE , -
IlltheapplicantorfuNreb
It(
occupant store or handle hamrdou. FfEATINGUMT( 1W,WOU Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I and Safety Code Section 75S37(a)7 FIFATINGUNIT(OV 100, BTU) TOTAL:
yes N No
-
Illthe applimntt or Mture building occupant on equipront or devices VENTILATION FAN CSE RESID) ISSUAIaCE.DATE•
which emit ham rdous air contaminants as dell nod by the Bay Area Air R� 13.
Qua lily Management DisMd7 BOILER-COMP OMa R1 IXq BTU)
Yes ❑❑No
Iha.ereadthehammousmaterialsrequimmentsunderChaptei6.95of BOILER-COMP E 300' N) T-9s9IJ
the California Healthk Safety Cod,Sections 75505,7SS33 and 75534.1 . rl wi
understand that if the building does not currently have atenant,that it is my NEWRESID- ALMECH. SQ.F.
responsibility to notify the occupant at the requirements which at be met Clay Of CQgP, llrta.
prior to Issue nee of a Certificate of Occo pa ncy.
.. Owner or authorized agent Date - /1 ,•
• Irl� .. #TOT
. . ISSl1ED BY:`�'h _
OFFICE COPY