20272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY! .
Building Project Identification - - PERMIT NO.
Building Add ares: -
s -7 4)
era arrc: r one:
�i VeICv15 2�JS--/.r7-9 CITY OF CUPERTINO-BUILDING DIVISION
c°n atlo eName: m.No: APPLICATION /PERMIT U
g m l t C.h 3 b�13 CATEGORY CONTROL N
rcbita seept BUILDINGELECTRICAI.PLUMBINGMECHAMCAL 606-3 O O 2
LA F Is Ta Llc`No: F J
b r �BUILDING PERMIT INFO
QIY ELECTRIC PERMIT PEE
Ad re 14it 2o7lop PERMITISSUANCE '❑ "❑ ❑'
LICENSED CONTRACTOR'S DECLARATION
Iherebyafftrmlhat l am licensed under provisions of Chapter 9(mmmenc- APPLIANCFSRESIDENTIAL JOB DESCRIPTION
ingwith SeRion70DD)of Dlvisim3 ofthe Buslnessand ProfemionsCode,and my
hunse is in full force and effect. PANELS
License Clam Lie# '
Date Contraclor - '
ARCHITECT'$DECLARATION 201 V -
ggqQ�Pc�±.,z I understand my plans shag be used as public records OVERIODOAMPS . SQ.FT.FLOOR AREA $/SQ.FT. _
t�zbzj Licensed Professional SIGNS ELECTRICA
6 OWNER-BUILDER DECLARATION SPECLILCR GSC b f l G
z� Ihereby affirm that l am exempt fromthe Curnnutor'sLicense Law for she
r4o foll6wmg reason.(Section 7031.5,Business and Professions Code:Any tlty or
c°untywhkhmquireeaperm(tlommtmc"teplmpmve,demolbhormpair TEMP.MECFRORPOLE
� anystmu mprimtoibbsuance,alcorequirestheapplimntf°reochpermltlo POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
GpOI 3°i Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. VALUATION
In SWBr1MING POOL ELECITIC
the sI.
bass for the alleged FrofeaWn. Any violatiat on
of exempt therefrom and R S—�La
0 the bash for the alleged exemption. Any violation of penalty
on not m re any OVIIE.ISSN7.CCL{FS F$ / / Z-
applcantfors permit subjects the applicant toativll pensltyolnol rnrethan tp( -
fivehundreddollars($50N. NEW REkl)EMI "E
❑I,age owner of the property,or my employees with wages age their sole STORIES TYPE CONSTRUCTION
Q, KA
compensationwlll do the work and the structurebnot intended or offered for i • �_ A/'r
O sale(Sec 7044,Business and Professions Code:The Contractors License law V (Y
does not apply to an owner of property who builds or improves thereon,and W Y JUN 08 19OCC.GROUP . - RES.UNITS
who dcossuch work h(mselforthrough his own employees,provided that wch
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcomplettion,the owner-builderwill have '
< rdenofproving that he did not build or improve for purpose of sale.). QTY, (hPE FLOODWNE APN
L-f L as owner of the property,am excivaively contracting with licensed I, i
WAfl
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such plojetls with a FEE SUMMARY
c0 61
licensed pursuant to the Contractor's License Law.
u 1 am exempt under Sec B&P C for.this reason BACK FLOW PROTECT.DE'NCE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a cortificate of consent to self-InsureA,or FIXTURES'PER TRSCIdOOL TAX Y - N
ceficate of Workers Compensation lnsunncere
ora certified copytheof($ec. �#
rti
3800,Lab C.) GAS EA.SYSTEM-1INCA OUTLETS PARK FEE - Y_ N_
Policy N - RECEIPT#
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES '
Com
b hereby fumishad. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Vr,g
❑Certified copy b filed with the cityhapection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ' SEWER-SANITAAYSTORM EA 200FI Date Recei t#
(This section need not be completed If the permit is forom hundred dollars
($100)orlem.) ATER HEATER W/VENT/Q.FLTR ENERGY FEE Y N
W
I cortifythat In the performance ofthework forwhlch this permit Is Issued, 6,2— OQ
1 shall not employ any person in any runner so as to become subject to the WATER SYSTEM/TREATINGWorkers Compensation Laws of California.Date' PAID .
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FC. DateRecei t#
Z O NOTICE TO APPLICANT:];after making this Certificate of Exemption,you -
shcold become subject to the Workers'Compensation provisions of the Labor TOTAL:'
p2 Code,you must forthwith comply withsuch provisions orchis permit shall be BUILDTNG
LU D deemed revoked. _
FEE U
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL lhereby.Mrm that there b a construction lending agency for the perform ELECTRIC FEE
M O ance of the workfor which this perndt b Issued(Sec.3097,Civ.Q TOTAL:
V Lender's Name PLUMBING FEE
LL I- Tender's Address QTY, MECHANICAL PERMIT FEE . MECHANICAL FEE
OW 1certify thatl havereadthis applcationand statethattheabove information
C Isccrmct.I egreeto comply with all city and county ordinances and state laws PEWI'TISSUANCE F ES Alp: /�
} W relating to building constroRion,and hereby thorlu representatives of lhle - w b
L. cityloenterupontheabodaZilybnedp for impaction purposes. ALTER OR ADD TO MECH.
? (We7 a gee to cove,in and harmleas the City of Cupertino Date Reeeiptif
V ag net li 'Ides,}ad rata,costsende nses which nuyinanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag st sal By in c s ce o(lhe soling of this permit.
AIR LiANDLINc UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Slgnamreo(App r cal/cnnaaRnr t Dale EYHAusTHOOD(W/DLCT) CONSTRUCTION TAX PAID: '
I. 2ARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle huardous HEATING UNIT(TO 100,000 BTU) Date Recei tit
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes . MNo -
Will the applicntorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)' ISSL}O[�j,C, ATE
which emit hazardous air contaminants as defined by the Bay Area Air - ®®,
a
lily Management Distrlct7 BOILER-COMP QHPOR 100,000 BTU)
Yes II��l No'have read the hazaouematerials requirements underChapter 6.95 of MOILER-COMP(OVER 100,000 BTU) JU�1 0 8199p
the California Health&Safety Code,Sections 25505,25533 and 25534,I
understand that lithe building does not mmently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUEDBY:
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OFFICE COPY