22002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ouildleg Project Identification PFRMITNO,
BuOding Add 000J u 22002_200
m
nems cc: V sone: A . 1 A A
d Zsb CITY OF CUPERTINO-BUILDING DIVISION
notrart��� Lie.No: APPLICATION If PERMIT
BUILDING-a ECTMCA4PLUMBINGhIFiCHAMCAL CATEGORY CONa Ay
Architect/Englneec Llc.No: �q�C J 1
QTY ELECTRIC PERMIT FEE BUILDING PERYMMIIT(INFO
Addrcu L/(J I
PERMITISSUANCE IN
LICENSED CONTRACTOR'S DECLA ATIDN VVV���111
I hereby affirmtFat lam lkensed underproviNons of Chapter9(mmmenc APPLIANCES-RESIDENTIAL OB DESCRJ[PHON
Ingwith Section 7000)of Divisloo3ofthe Buslnessand ProfevlonsCode,and m
license Islnfull force andPANS L
License CVs le.0 I Q �
Dae Contneor —UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1UW hMI'S
x Z I understand eny plan shallbe used as public records. OVER 10D0 AMPS SQ.FC.FLOOR AREA S/SQ,Fr.
COC
s� U Licensed Professional
SIGNS ELECTRICAL I I� ""IN' N ' Z�
<Gto OWNER-BUILDER DECLARATION �^t t�l
rn r'6 0. SI'GCIAL CIRCUIT/MLSC
y Ihercbyaf0rmthatCam exempt from the Contractor'sLlcensefawfw the
OgFa following reason.(Section 70)15,Businevand Professions Code:Anyctty or 'TEMP.METER OR POLE INST. I�
to county which requires a permit to construct,alter,Improve,dennlbh,oreepair 6—
anystroctureprlorte,Its tssuame,atso requirestheappRnnt forsuch permit to POWER DEVICES
�^ file a signed statement that he is Ikemed pursuant to the provisions of the
520w� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- NG POOL ELECTRIC TE
sion3 of the Business and Professions Code)or that he 2t!n
iu30 a exempt therchomad �7T N
H Sn 3 the basis for the alleged exemption. Any violation of Section 7031.5 by any -
<9 OIJILETSSWITCHFSFT%Tl17tFS l
a 0
applicant permit the applicant to civil pealtyotnot more than
five hundred dollars(S500). NEW RESIDENTIAL ELECTRFT.
❑I,as owner of the property,or my employees with wages as their sole �' STOW FS TYPE CONSTRUCTION
>� mmpensation,wEl dothe work and thestructure bred Intended or offered for
0 sale(Sce.7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through hlsownempioyees,provided thatsuch
Improvements are not Intended oroffered for sale.If,howevcq thebuilding or TOTAL:
improvement!widwithinomyearofcomploion,theowner-budderwdlhave
n ofproving that he did rout build orlmprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
s owner of the property,am exclusively contracting with licensed ' PERMIT ISSUANCE I�
ntracmn to construct the project(Sec.7014,Business and Professions Code: ll
e Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) 2x
builds or Improves thereon,and who contracts for such paojeca with a
,0.t snorts)Licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ 1 am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE 0 OUTSIDE FEES
% Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT N
nes WORKMAN COMPENSATION DECLARATION n F.IXS � SCHOOL TAX Y_ N_
J,❑I hereby affirm that I have a certificate of consent to self-inure,w a W PER TRAPt RECFL'F N
certificate of Workers'Compensation InsuranceS ora certified copy thereof(Sec.
360D,late C.) C GAEA.SYSITM-1 INCA OUTLETS PARKFEE Y_ N_
Policy N RECEIPT M
Com any GAS EA.SY5CFM-OVER4(EA) BUILDING DIVISION FEES
Ceaifted copy is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
E]Certified copy is filed with the city inspection division.
CERTIFICATE OF E%EM PFION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200Ff. Date Remi t# MaL+0
(This section M slon need not completed d the permit Isfororm hundred dollars
(g100)orlesa.) l WATER HEATIRW/VENT/ELECTR ENERGYFEE Y_ N_
1 certify that In the perforreanm of the work forwhich this permit is issued,
1 shall not employ any person In any manner ro as to become subject to the WATERSYSTEM/TRFATING
Workers'Compensation Laws of California.Date PAID 9!3�
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Reeel t# V+�t�
Z O NOTICE TO APPLICANElf,after making this Certificateof Exemption,you
should beceme subject to the Workers'Compensation provisions ofthe Labor TOTAL:
W Cade,you must forthwith comply with such provisions or this permit shall be 300
W m
>deeed revoked.CL BUILDING ' _
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O Ihereby affirm that there is a construction lending agency for the perform ELECTRIC FEE s
M Z arm ofthe work for which this permit is Issued(Sec.3097,Civ.CJ TOTAL:
() O Lander'.Name PLUMBING FEE -.it
LL H Lender's Add reu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certifythat l have read this applicationand rtatethatthe above information ,eta'
O W lscomect.7agrmtocomptywilhaB cttyand countymclinancesand statelaws PERMIT ISSUANCE �W FEES PAID:
} 1 relating tobullding construction,and herebyauthomereprexntadvesofthb sft
1� Z dtytoenteruponthe above-mentioned property for Impectlon purposes. ALTERORADDTOMECH. Dale RCCe1Pt#
(We)agree to save,indemnify and keep harmless the City of Cupertino AIR HA 11MT TCO 10,000 CFM)
V agaften habillties,jadgrants,c LA..rd ez rases which may in any way amue SUBTOTAL:
ag.ostsaid ityie con t an ng cur thio Parma' CONSTRUCTION TAX
Jr-�3_ �,� AIR HANDLING IINR(OVER 10,000CFM)
gra rc Ap /Co ract Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE �-RT
ill the applicant or future budding occupant store or handle hazardous BEATING UNIT(TO 100,000 BTU) tJU Date ReceI [#
tectal as defined by the Cupertino Murddpal Cod,Chapter 9.12,and the -
allh and Saf&y Cdr Scc ion 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes N No
willtheappllcant or Notre building rscvpant use equipment or devices VFN71LA DON FAN(SINGLE RFSID) I ISSUANCE DATE
�( hich emit harardous aircontamianlsas dented bythe Bay Area Air
Quality Maagemcnt District? BOILER-COMP OHPOR I00,00 BTU)
Yea n No
have read the haeimmus materials requirements under Chapter 6.93 of BOILER-COMP(OVER 100,000 B1T1)
,t)a the California Health&Safety Code,Sections 25505,25533 and 25534. 1
.,i.l✓ and erstand that if the building does not currently have a lena.I,that It is my NEW RESIDENTIAL MECO. SQ.Ff.
responsibility,to notify the occupant of the requirements which most be and
prior to issuance of a Certificate of Occupancy.
Owner or authorised agent DateISSUED BY;
IO'fAL.
Y
OFFI OP