20132 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
9 A'-1,,eW ,11_sn, ZAO 20132
nen sets, one:
A
caJjN/G: P-aa zz ( 0 CTOFCUPERTINO-BUILDING DIVISION
Lia N. APPLICATION I PERMIT l
Architect/Engineer. Llc.N. SUMDINGELECTPICAGPLUMBING-MECHANICAL CATEGORY CONTROL N
QTY ELECTRICPERM F FEE BUILDING PERMIT INFO
Addrcsc pERMITISSUANCE —0 El ❑
LICENSED CONTRACTOR'S DECLARATION
I hnnaby hsecti urri,7Dthat]am Bcensed 3oftheunder provedmis and Pro Cssl=s ode,an my API'LIANCESRESIDENTTAL JOB DESCRIPTION
lame,I.uctlon fmcoinO)of Divfect. fthe Buslnesand ProfeeelonsCode,end my
Ilanse le In full force and effect PANELS '
Llcens Clots Lk.M 1 �Q /`Ti
Date Contractor l.. ( l \ V
ARCHITECTS DECLARATION 201-1000 AMPS
2 I understand my plane shall be used as public remrda OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
{9 O
do Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION 9'ECIALCIRCUIT/MIST
Ihereby affirm that am exempt from the Contractor's License law for the
fotlewing rcawn.(SMlon 7Q715, si
Bunm and Professions Code: al or
O t. y y TEMP.META ORIOLE INST.
cmnly which requlrem
sa pedttemmro
tct,alter,Improve,de=113h,or repair
y anystroctum prior to its Bsuance,also requires the appliant(orsuch permit to POWER DEVICES
cG 5 (clic a signed statement that he is limned pursuant to the provisions of the
3kG Commeor's Liceeae Law(Chapter 9(mmmencing with Seaton 7000)of Divi. SWIMMING POOL ELECTRIC
I„IyOs slon3ofthe Businesand Profesoom Cad0ruthat he a exempt themfromand VALUATION
<� the basis for the alleged exemption. Any violation of Stolon 7131.5)'y any OUTLETSSWITCHGSHXTURES I, vO
11 applicant fora permit wb*dsthe applicant to a civil penalty of not mom than Q
(Iv�r J:undrcd dollars(§500). 00 NEWRESIDENTIALELECIR_SQ.Ff. Simms TYPE CONSTRUCTION
�n u I,as owner of the property,or my employees with wages as their°ole
compensation,will dothe work and thestruchom is not Intended or offered for
O sale(Sec.7074,Business and Pmfeslov Code:The Contractors Licame Law
r� does not apply to an owner of property who builds or improves thermR and OCC.GROW RFS.UNITS
whodwssuchworkhimself orthreugh hisown employees,provided that ach
Improvements,are not intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement issold within one yearof completion,the ownsebullderwill have
t"rden of proving that he did not Wild or Improve for purpose ofasle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively...rant..with used
contractors to construct the.project(See,7074,Bustnm and Prefislore Code: PERMITISSUANCE
The Contactors Limine Law does not apply to a wast of pro who ALTER-DRAIN 4 VENT-WATER(EA)
builds or Improves thereon,and who metra r such V. with a
actor need pursuant to the Contr Irons La BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am an apt under Ser. B 4 P for FV awn
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
O.vner RECEIPT M
VORF'N MP rtific (ARATION FIXTURES PER TRAP SCI IDOL TAX Y N
❑ rcby of{I th I Fav artlflc't consent to"If-insure,ora RHC te,p
eSoifl eofW rl 'Compere roars ora artlfled ropytherco((Sec. GAS PA.SYSTEM-1 INCA OUTLETS PARK FFR Y N
Polisoo, t
Paltry M GAS F.A.SYSTEM-OVER d(EA) RECEIPT N
Com any tlU1LDING DIVISION FRES
❑C
ertified copy is filed furnished.city GREASE/TNDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certl(IN mpy V flkd with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSIORM EA 2(071, Date RL i t#
(Thor seniors need not becomplaed If the permit isfor cam hundml dollars
(5100)oily that
mrehlWATER HEATER W/V�./ELECIR ENERGYFEE Y N
Iartifythat In the performance (orwch this permit le Weed, —
I shall not employ any person In any manner an m to become abject to the WATIR SYSTEM/TREATING
Workers'Compensation[Am of California. Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z NOTICETO APPLICANT:If,after ma king this Certificate of Exemption,you
should become subject to the Workers Compereation provisions of the Labor TOTAL:
CC N Code,you must forthwith complywith such provisions orthis permit shall be
> deemed revoked. BUILDING FEE 7 a
LU
mCONSTRUCTION LENDING AGENCY SEISMIC FEE -�
I hereby afflrrethzt there is a con rtrualon lending agency forthe performELECTRIC FEE
D Z once of the work for which that permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Iender.N.me PLUMBING FEE
LL ~ Lenders Addrees QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
OW 1whifylhat l have read this appllatlonand statethat theabovelnformatlon
1 bcorrn".Iagrcetoaomplyealth all eltyand countyordlnances and statelaws PERMITISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize repreiontativer of this
Z city to enter upon the above-mentioned grope or WprcCm purpo ALTER OR ADD TO MECH.
egrce to eve,IndFmnl(y an d keep _micas the Chy m Cu Ino Date Receipt#
agabu llabllltln,pAgment,coa.andJ�pe which may In any a scan AIR HANDLING UNIT RO 10,000 CFM) SUBTOTAL'
agai uld Citylmm�sequenreof fe gt' In ofthla permit.
1� ! / AIRHANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
�[- nature that/r1_1
n or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA OUSMATF k OSURE
W eapplicant or to IB ng occupant store or handle hazardous HEATING UNIT CM 100,000 HIM Date Recei t#
ma aade0ned'byt Cupertino Municipal Code,Chapter 9.12,and the -
If h and Safety Code Section 2S532(a)1 HEATING UNIT(OVER 100,000 HIM TOTAL:
❑
as ri No
Will the applicant or future building occupant use equipment ordevores VENTILATION PAN(SINGLE RISID) Ij DATE
which emit hazardous air contaminants as defined by the Hay Area Air +/
Quality Management District? BOILER-COMP OHP OR 100,000 BTU
4 Ya No 1
have need the hon ".0meterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JgpD 9yy
the Califomte Health 4 Sal Code,Senoons 25505,75537 and 2553.1 APR R
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
resporelinllty to notify the ocmpant of the requirements which most be met sr ,.{4p ,,a�M,
prior to issuance of a Certificate of Om pa ney. city.u7 V.Mfing
Owncrmr authorized agent Date TOTAL: ISSUED BY: ��j/
OFFICE COPY