20577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMMITNO.
Buliding1 ddress:2 't V L 20577 O r 717
`ereAPpucAG ITMA,J I
r sere. _eras CITY OF CUPERTINO-BUILDING DIVISION G
rador's Narre: Ile.N APPLICATION I PERMIT
ry. C•z "a BUILDINGELECTRICALPLU.NBINGMECHAMCAL CATEGORY CONTROL M
Arc sleet/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE a D ❑ 1:1LICENSED CONTRACTOR'S ECLARATION
I hereby affirm that l am licensed under prewhionsofChapter9(commenc- APPUANCESRESIDE 1, 08 DISCRI'TION
IngwithSMion70f1D)of DlAsbn3ofthe Businessand ProfessionsCode,andmy � d /�♦
Llcenss ICI n In dLic
ue a2� F'
M_ . 3 ' y PANELS ]V
Date Contnd �.
ARCHITECTS DECLARATION 201-1000AMI
MVLicensed Professional
I understand my plan shag be used m pubbc record& OVER 1 W0 SQ.Fr.FLOOR AREA $/SQ.FC.
ww O nal NS$LEC L
�j
OWNER-BUILDER DECLARATION EC LCT T
71' 2 Iherebyaffirenthat l am exempt from the Contractor's License Law for the
O O following reason.($action 70315,Business and Professaov Code:Anor repy city alor M E I
rr4E'u� muntywhkh requimaperMtromnsteuct,alter improve,dennlfsh, r
anystructure pdorto its asuance,alsorequlresthe applicant forsuob pereed
a file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(CMpter9(commencing with Section 7(W)of Davl- LELECTRIC
X05 sion3ofthe Businessfess
and ProlonsCab
de)orthat heexemptthsmfmmand VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.51 any OUTLETS TCHESFT%TURES Q
�J applicant fora permit subjects the applicant to a civil penalty of rad more than
C`u five hundred dollars($5500).
❑I,as owner of the NEW RESIDENTIAL ELECTR SQ.FC. STORIES TYPECONSCRUCTION'
property,or he employes with wages as thele sole
compensation,7044,Businesswill do workandtheatrudure VIWIntrandN oroffered for
sale(Sec.apply
to Business and Professions Code:The Contractors License Law
({�$
does not applytoanowvrolProperty who nempoNes,pro provided atsuch OCGGROUP RES.UNUS
E: Improvn,and
whodeme :1.orkhimse dedoewgh his own IL owe,r.tha dth angor .�
improv=iarcnotintended earofcdfarsale.t howeveg ildef ilI have TOTAL:
Improvement V wld withlnoneycarofcompletbn,tMowner-bullderwill have
the burden ofpmving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Buslnm and Professions Code:
The Contractors License law does no apply to an owner of property who ALTERDRAIN&VENT-
buBds or improves thereon, and who contracts far such pSojM -
s with a WATER(EA)
g1�Cadm(a)licensed pursuant to the Contrader's License Law. FEE SUMMARY
c I am exempt under Sec. BACK FLOW PROTECT.DEVICE OUTSIDE FEIN
B k P C for this reason
DRAINS FLOOR ROOF,AREA,CIONI. SANITARY Y_ N
Owner Date RECEIPT#
WOR"AN COMPENSATION DECLARATION FIX.NRFS PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that 1 have a cedlflate of consent m'sel(-Insure,ora RWE PT X
urti(Icateof Ncrkers pensatfon Insurance or a certified copy thereofelac.
' GAS EA.SYSTEM-1 WCA OUTLETS PAK FEE Y
ryLNb _ _
I wic RECEIPT Q a0
GAS EA.SYSTEM-OVER4(EA)
BUILDING DI VIS ION FIi T.S
Certified copy is hTmeby ththes GREASE/WDUSML WASTE INTERCEPTOR PLANCFIECK FEE
ertified ropy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SATARY-STORM RA.200FC. Date RCCeI t#
Qhis section need not be completed lithe permit is for aM
ne hundred dollars
(gl oo)orfetWATER HEATER W/VENT/M TR ENERGY FEE Y N
I certhat in the performance of the work for which this permit permit la issued,
1 shall not employ any person In any manner a u to become subject to tM WATRI2 SYSIFM/TREATING
Workers'Corepensatsm Lawsof California. Date PAID
-
z Z Applleant NEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z Q NOTICE TO APPLICANT If,after nodding this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
H N Code,you=at forthwith comply with such provlalons or that permit shall be
W > decreed revoked. BUILDINGFEE
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a construction lending agency for the perform- Tornl: ELECTRIC FEE
anceof the work for which this permit b Laved(Sec.3097,Civ.C.)
00 LenderbName PLUMBING FEE
Iy F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I certilythm l have read this application and statethattheabove information
O W
1 is correct.I agree to comply with al city and county ordinances and Gate laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authorb<representatives ofthis
I.- N city to enter upon the above�mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V a WtllabiW ,�rdgmen4,roots and evpenma which rvyln anywa attae AIRHAN )LINGUNT(TO 10,000 CFM) SUBTOTAL:
a team t Inco an oft grantingof(hIspa AIRHANDLINGUNTT(OVER 10,000CM) CONSTRUCTIONTAX
4G -
0.O CONSTRUCTION TAX PAID:
Signatureof ppliant/Con dor D(EIAL15'C HOOD(W/DUCT)
HAZARDOUS MATERIALS DISC LOS RE a
Will theapplium or future building occupant store or handle hazardous HEATING UNIT CTO IKODO BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
IIcalt Yaennd Safety Code,Section 2 32W? HEATING UNIT(OVER 100,M BTtp TOTAL:
No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hassrdous air contaminants as defined by the Bay Arca Aar /�
Quality Management District? BOILER-COMP QH POR 100,000 BTU) PAID
Or JY. FI No k.IL�
(have re ad the hazar7ious materials requirements underChapter6.95 of BOILER-COMP(OVER 100,000 BTL) - ,I UIV 1 s71JJU
the Glifomaa I ialth h Safely Code,SMiona25505,25533 and 25534.I
understand that if the building does not arrently have a tenant'that it is my NEW RESIDENTIALMECH. SQFT
responsibility to notify the occupant of the requirements which at be met .a.
prior to isauance of a Certificate of Occupancy. city Of`.Cupertmm ,
Owner or authodvd agent Data ISSUED BY�c `.1' V�G
TOTAL: 1
OFFICE COPY
I