22317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PHRMITNOO. f/�PSS 17
Bulldln;d� Crc-5 2 LI V 1 1
_Ms
wne,x51aGame: � AA� 1 one:
50 C'-Mw 0 K� x(05 y CITY OF CUPERTINO-BUILDING DIVISION
G°"rt• " • U APPLICATION / PERMIT fG
BUILDING-ELECTRICALPLUMBING-MEC}IAMCAL CATEGORY CONTROLX
Architect/Engineer. Lc.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres> PERMITISSUANCE
LICF.NSEDCONTR under provisions
�f �f
I hereby
((Irtnthat Dim.i 3afthe Busiro landPmfeWmsr9(commrna MPLIANCLSRFSTDENIIAL JOB DESCRIPIION
Ingwith Sec0on70W)of Ovislon3o(theBwinsnnd Professions Coda,and my r�
license Is In full to d dfM. Eppppp19) PANEIS G a 1
License s _ LIe M15 S W t k'Y�m 1a a"1 C f/
Date Contactor ._/
ARCHITECTS DECLARATION 201-IODOAMPS
mOZ l understand my plana shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
ELicensed Professional SIGNSELEC
6 ° OWNER-BOLDER DECLARATION SPECIALCIR T q0O
zl-, 7a Iherebyaflme that Is.exempt from the Contractor's License naw for the a
qqqq following reasen.(SeM1°n 7031.5,Business and l'mfessbne Code:My city or
F t'ry countywhlch requires a permit to construct,alter,improve,demolish,orrepalr TEMP. O LEN .
°'3 X77 anyauunure prior to its lmvance,alw aetryirestheappliam fonuch permit to
O6 file a signed statement that he is licensed pursuant to the provbloru of the POWER DEVICES
�36 Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWBdMI CI'00
� 5 alun3ofthe Busffi—.dProfessb.Code)orthat heisexemptthere(romand VALUATION
< the basis for the alleged exemption. Any violation of Section 70315 by any OUTLET✓SWI•fC11ESF1X.NRFS
applicant fora Formed subjects the applicant to a civil penalty of nm covers,than pC
Bvehundrecidollzrs(E500). NEW RESIDENTIAL ELECTR_SQ.FT, STORIES
❑I,as owner of the property,or my employees with wages as their sole TYPE CONSTRUCTION
k 6 comperuadon,will do the work and the structure h am intended or offered for
D sale(5ee 70K Business and Professions Cade:The Contractor's License Law
$ does not apply lose owner of propertywho buildsorimproves theroon,and
OCC.CROUP RFS.UNITS
workid reseBarthr°ugh Ms°wnempoyess providedthatsuch
Improvements are am intended oroffered fm sale.It,however,the building or TOTAL:
Improvement issold withl"oneyearofcomplMbe,the°caner-builderwill have
ll(�urdenof pmWnglhat he did not bund orimprove(orpurposeofuk.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rostra hum to cor.MmM the project(Sec 70K Bushes and Profenl°ro Code: t
The Contactors License law dos am apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
Wild.or Improves thereon, and who¢ntaeb (m such pkojecta with a
cgRt(�Mort.)Ilcenmd punuant to the Conbanora License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this mownOUTSIDEFEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RFCEPT X
WORKMAN COMPENSATION DECLARATION pp(TURM PER TRAP �(� SCHOOLTAX Y N
QI hereby affirm that I have a certificate of consent to.elLlnwre,ora RECEHvr X
certl0ate of Workery Compenatlanlrourancocoa certified ropy thereo(0iec.
3800,IAb C.y. GAS EA.SYSTEM-1 INCA OUTLETS PARK FFP Y_ N_
Policy Y k/.11[u C Ll I9 �'e RECEIPT X
Com anv J11a 5iP/� N, O GAS.EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cc
copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
[� Cediflxd copy is tiled with the city ispection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID (0/2 /9/ �z?95
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Remi tp I3
RMs seion need n
ctm becomplMed Ella,permit Joforone hundred dollars
(n I carifyth WATER HEATER W/VENT/E-ECTR ENERGYFEE Y N
IcertOy thatbthe perfemun¢°fthe weak(°'watch this permit Is WuM, —
I shall am employ any person In any manner se m to became subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Data PAID
C' Z ApplicaNOTICE NEV RESIDENTIAL PLMB. :n.Fr. Date ReCeI t(l
Z NOTICE TO AI'I'LICANT:IL ager making this Certltla/e a(Exemption,you
should become subject to the Workers Compensation provbioru of the Labor TOTAL:
V7 Code,you mu at fort hwlth comply with such provisions or this permit shall be
LU j deemed revoked. BUILDING FEE __L)L�cx
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby a(flrm that there is a construction lending agency for the perform- TOTAL; ELECTRIC FEE t(p
ance of the work which this permit is Wued(Sec.3071,Civ.C.)
V O Lender'.Name PLUMBING FEE
IL F Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlfythatl have read thhappliati.rand Mate thatthe.bove Information t
1 Iscomod.I agree to comply with all cityand county ordln......d Mate laws PERMIT ISSUANCE G� PEES PAID:
>. N matingtobuliding construction,and hereby authorize represenlatien ofthb
j. U) city to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDTOMECH. Date Rete( Elf
— (We)agree to save,Ind emnily an d keep harmless the City of Cu ped Ino
against liabilities,Ydgments,cases acid expenses which may In any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
ngxiostald ity Tnconse uenceoft rantlegmtlels rent.
AIR HANDLING UNIT 10,"CFM) CONSTRUCTION TAX
Slgrutureo App cant omracior to ID(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM ERIALSDISCLOSURE
Will the applicant orfuture bulldigoccupant sore or handle hazardous HEATING UNIT CTO 100,00 BTU) pate RCCCI IN
materlal as defined by the Cupertino Municipal Code,Chapter 9,12,and the
HeAth and Safety Code Section25532(e)2 HEATING UMT(OVER 100,000 BTU) �� TOTAL: .
❑Yen ISJ^1O
Will the applicant or future building occupant use equlpment or device. VENILATIONFAN(SINCLE REB ID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air )As
Quality Management Dintd 7 BOILER-COMP O}@DR1W,B(D BTU) 1�
4Yee o '
have read the Nazar °sass materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) c
the Cxllforni.Health&Safety Code,Sedi..25505,25533and25534, I
understandthatitthebulldingdoesnol¢rrently have atenanq that it loony NEW RESIDENTIAL MSCI 1. SQ.FT
rmponel6B ty to amity the oatpant of the requirements which must be met
prloNo ices ace of a Ce fl to of Panry. /A CRY M
Owner°raulhorimd agent J-Z'L(_�cA`�17I fWte _I ISSUFDBY: V'b
TOTAL:
OFFICE COPY