19866 APPLICANT TO FILL IN.INFORMATION WITHIN REDLINES — USE BALL POINT, PEN ONLY `
Building Project Identification P' TNO.
' Building Addrese: a 17 � �` :` � � 19866
nera
CITY OF CUPERTINO-BUILDING DIVISION - "
`r'd°" ' Lle. •APPLICATION / PERMIT 3 S
. tp
,
A act/Engineer. BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY . CONTROL If -
d m .BUILDING PERMIT INFQ `
r Q ELECTRIC PERMIT FEE
Address: - /o /
D PERhRTISSUANCE ❑ ET 'E]
TENSED CONTRACTOR'S DECLARATION
Ihreby affbm thtlamllcaseduhderprovist°n.of Chapter9(cemmac- APPUANCESRESIDENTIAL JO DESCRRa'IION
iniwlthSecHe 000)ofDiWsion3oftheBusimmandProfesstovCode,aadmy
liaveisinful force doffed. PANELSLicense^has ` Lic.M'�0�. ,2 Y�
- Date O Contrado a
ARCHITECT'S DECLARATIO 701-1000 AMPS
0O Iunderstand my plans shall he used as public OVERI000 AMT'S - SQ.FF.FLOOR AREA S/SQ.FT." '
ensed Pro(eselovl' SIGNSELEC CAL
Lic
�6 OWNER-BUILDER DECLARATION 'SPFGIALCR(C
z ' Ihereby affirm that I am exempt from the Contractor's Llcenm Law for the
O ., following reason.(Section 70315,Busihesn and Profemlons Code:Any city or •-
p�a' ITiMP.M O LE IN
c°unlywhich requires a permit tomvtrue"ter,Improve,demolish,or repair
any atrudu re prior to its bw a nce,also requires the Applicant for such permit to
file a signed statement that he is Licensed pursuant to the provisions of the POWER DEVI a.
'3 u, Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- -
ISO Mon 3 ofthe Businees and ProfeseiumCode)ortiot he is exempt therefromand N L C VALUATION
< the baste for the alleged exemption. Any violation of Section 7001.5 byany O E TC FI)C[VR
applicant(ora permit subjects the applicant to a civil penalty of nor morethan
w five hundred dollars($500), NE DENIAL L
QQQ �n ❑I,as owner of the property,or my employees with wages as their sole SQ3'T. SCO FS TYPE CONSTRUCTION
compensation,wRldothe work and the structure Is not intended oroffered for
O sale(Sec.7094,Buelvas and Pmfeaelons Code:The Contractors License Law
$ does not apply to an owner of property who builds or Improves threon,and ' .
who does suchwork himself orthrough his own employees,provided that such OCC.GROUP RES.UNITS
Improvements are not intendeaur offered for sale.If,however,the building or TOTAL:
improvement issold Mthinoneyearofcompldiogtheownerbulkierwill have -
t4t4urden of proving that he did not build or Improve for purpose of sale.). Q7y, PLUMBING PERMIT FEE -T fppDz NE
u I,as owner of the property,am exclusively contracting with licensed PERM IT ISSUANCE pPN
contractors to ceretrad the project(Ses,7044,Business and Professlons Code: _
The Contractors License Law does not apply to an owner of property who - -
builds or improves thereon,and who contract for much pTjects with a ALI'EWDRAINr k VENT-WATER(EA)
c'�j(ador(e)licensed pursuant to the Contractor's License Law. _ BACK FLOW PROTECT.DEVICE FEE SUMMARY
u Lam exempt under Sec. B k p C for this reason
OUTsiripprEs
Owner Date DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y. - N_ '
WORKMAN COMPENSATION DECLARATION - REECER'L p
• ❑I hereby affirm that I have a artifkate,of consent to self-Insure,or a FDCTDRES-PER TRAP SCHOOL TAX
certlficece of Workeri Campevatienlnsuranaora certified copy thereof(Sec. 'BBC=If
> '3800,Lab C.)�1 CT G GAS FA.SYSIFM-1 INC.40UTLETS PARKFM Y— N— -
PoHry X._/'- 9 RECEIPT X -
Coen any - GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
CertNdd efpyh hereby fumished.� GREASE/INDUSIRI.WASTE INTERCEPTOR PLANCHECKFEE
Certified copy h filed with the city inspedio division.
'CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY SIDItM EA 2tKQT Date' •Re i tN
(This section need nbe completed if the permit h one for ohundred doll am
($100)orleth) •' ' " WATER HEATER W/VENT/ELCTR ENERGYFEE. Y N
I snot employ
in oy he any person
I cany manner
as to b co permit is issued. —
I shall not employ any person is any manner ao u to become subject t' the WATER SYSTEM/,CREATING
Workman Compeneatbn Lawsof Callfomla.Date PAID -
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FC. - Date ' Recei t44
should become subject to the WorkersCompensation provhlov of the Labor - TOTAL:
~ N Cade,you most forthwith comply with much provhlov or this permit shall be
UJ >' deemed revoked. BUILDING FEE U
(L G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there h a ronstrudlon lending agency for the per(orrrF
O ance of the work for which this permit is Issued(Sec.3097,Civ.C.) - '
•/J _ /ander'.Name TOTAL: ELECTRIC FEE
PLUMBING FEE
LL F Lender.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iwrtifythatl have reacithisapplication and statethatlheabove ln(omatlon -
6. iscoreact l agree tococeply with all city and countyordlnances and statelaws PERMIT ISSUANCE FEES PAID:
>- N relating to building conslmctloa,and hrebyauthorize representatives of thin
Z city to enter upon the above,mentinned.property for inspection purposes: ALTFRORADDTOMECH. Date Recei tR
(We)agree to save,indemnify an d kap harmless the City of Cupertino P
against liabilities,judgments,costs and expenses which may In anywayaccrire AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
agai t ald City ns cna°ffhegrantingofthispermit!
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
3-/S`-9e
Signs .of AppBcant/Contract Date EXHAL5THooD(Y✓/DI1C'D CONSTRUCTION TAX PAID:
HAZARDOUS MAT ALSDISCLOSURE
VIIII ache defined
bycant the future rtno ng occupart MurselpstCode, hhandleh and the,
HEATING UMT(T0100,ODO RTU)materDate Recei IM
Health
hand Eatery Cod the Cupertino Municipal Code,Chapter 9.12 and the. '
Heals Yea Safety C°da Ion 25537(e)7 HEATING UNIT(OVER t00,000 BTU) TOTAL:
. ❑ Yrs ��(f�Nto. .
- Will the appllant of num building occupant use equlpmentor devices VENTILATION FAN(SINGLE RESID) - I�DATE '
which emit hazardous ah cemammonte as defined by the Bay Area Air
Quality Management DisMd7 BOILER-COMP(3HP OR 100,000 BTU) '
❑Yes I�No
.� Ihave reid the hazatdO.a materials requirements under Chapter6.95 of ' BOILER-COMP(OVER 100,000 BTU)
the Celifomh Health k Safety Code,Sections 75505,75533 and 25534'.1.
understand that tithe building does not comentlyhave a tenant,that it h my NEW RESIDENTIAL MECH. SQFT.
responsibility to not ify the occupant of the requirements which must
prior to Issuance of aCedificate of Occupancy. Qt.
Owneroraulhorizedagrm Date - ISSUEDBY: I'`✓
-4" TOTAL:"
OFFICE COPY.