23994 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY i
Building 'Project Identification ` PTNO.
Building Addre
23994
ame. I lecon: I
P p
CITY OF CUPERTINO-BUILDING ISION
• CoetrachoraName: uoNo: APPLICATION PE IT
3 BUILDINGELBC CA4 UM 'GM CAL CATEGORY CONTROLN
Arehltect/ gine... Lk.No:
QTY ELE C ER F EE BUILDING PERMIT INFO
Addeaa:aa-rte ow PEMTi ANC L�71`
u ULICENSED CONTRAROR'g DECLARATION Qs
14
I hereby affirm that l am licensed under provisions of Chapter9(commm APP] NC SIDE JOB DESCRIPTION
ingwlth Sedion7000)of DtAsion3ofthe Businesaand Pmfes msCode,andmy / I __I7-` 1e.n '� ElA� -
licensebinfull( and dfect. LV!` �"CVe-pa�Y�
Ll.. Is Llc.N
Date r1' Contractor
ARCHITECTS DECLARATION 203 PS
qua m 7Z❑ I understand my plans ahall be,used ns public records. OV 1 AM ]'.FLOOR AREA S/SQ.FT.
Lioc."Prof.ssional SIGNS TRIC I '
6 OWNER-BUILDER DECLARATION
Gp Fn4&PFCIALCIRC /MLSC
i.., Ihercbyason.(that lam31.5,Bsiness the ContractorsLicense law fort he
O O Yd Q following reason.iresa p 7031.5,Business and professions Code:Any dry or gyp.M OR POLE INST.
PEE ul county which rcqulrcsa pemJttocomwct,alter,improve,derrolbh,orrepalr
qQ anystruture pdarto Its Issuance,alsorequiresthe applicant forsuch permit to ]'OWER CFS L
E U file a signed statement that M Is licensed pursuant to the provisions of the
�a Contractor's License Law fChapter9(mmmendngwith Section 79M)ofDivi- SWLMMNCPOOL ELECTRIC VALUATO
O stun3ofthe Business and PrefeselonsCode)orthat hels exem therefromand
Q lM bash for the a...gM exemption. Any violation of Se tion 7MIS by artf bUTLETS-SWITCHESFIXTURES
applicant fora permit subj vtheapplicant to a civil penalty of not more than
c. five hundred dollars($500). NEW RESIDENTIAL ELECTR
SQF7. STORIES =CONSTRUCTION
e as net will
of property,or my employees with wages a thele sok
C]0 compensation,Business andhe kand the stmcWrehe Is art IntendedContactor or License
ed for
Law
9�❑ sale(Sec.7004,Business and Professions Code:The Contractors Wcerxve law
S does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RES.UNITS
who doessuchworkhmeselforthr°ugh hisownemployees,provided that such
improvements am not Intended oroffered forsale.If,however,thebuilding or 7
improvementlssoki wllhinoneyearofcomplMtb the w er-WMerwill have
tljvkurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
"Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7004,Business and Professions Code: �e
Thu Contnctoes License Lw does na apply to an owner of property who ALTERDRAIN kVENT-WATER(EN
Wilds or Improves thereon, and who contracts for such p�ojem with a
cgtdEactor(s)licensed pursuant to the Contractor's License Law. BAC(FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this masonOUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y_ N_
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION TURE4IPER TRAP SCI100L TA% Y_ N_
❑I hereby affirm that 1 have a certificate of consent to self-Insure,ora RECEIPT N
certificatemW°rken Compensation❑xsurance ora certified copythereof(S.c. GAS EA.SYSTEM-1 INCAOUTLETS PARK ITE Y N
3800,lab C.) RECEIPT p
policyN GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDIYC DIVISION FE ES
Cenified ropy ls hereby furnished. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
I�ICetlfied mpy b filed with the city impetion division.
`/� CERTIFICATE OF EXEMPTION FROM WORKERS" GREASE TRAP PAID
COMPENSATION INSURANCESEWER-yIND.ABy-yTOBM FA 200I,"I' Date RCtt'1 t#
(Thlssectlon need na be complied if the permit ls forone hundred dollars
(f100)or lcasJ WATER BEATER w/VENT/ELECTR ENERGYFEE Y_ N_
I otedlythat In the performance ofthe m
e work far which this portent Is laed,
I shall not employ any person in any manner so as to become subject to the wATCR SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
I O Applicant Date Remi t#
Z NOTICE TO APPLICANT:ILaher making this CertRlcate of Exemption,you
NLW ftESIDENUAL PLMB. SQFT.
should become subject to the Workers'Compereation provisions of the Labor TOTAL:
hD Code,you mustfothwlthcomplywithwchprovdions°rthLpemdtshallbo BUI IN
G FEE
LU j deemed revoked.
LU
CONSTRUCTION LENDING lending
AGENCY - SEISMIC FEE 4
]hereby affirmthatthere lsac°nstmction lendingagenry forth.perform, TMZL: ELEC'T'RIC FEE
(� OZ .e..f the work for which this permit lslssued(Sec.3097,CIv.C.) _Ir PLUMBING FEE
larder's Name
Iy l— lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE s�
O W Imrtify that have mad this appliestionand statethat theahe I formation
Iscorrect.l agree to comply with all city and county orainancesand state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthls
FZ cilyto enterupon the abovcmcntlonei property for Inspection purposes. ALTERORADDTOMECH.
_
(We)agree to Pave,Indemnity and keep harmless the of Cupertino Date Receipt#
V against liabilities,pdgmenU,mate and expenses which may In any wayaccruc AIR HANDLING UNIT(TO t0,0D0CFhU SUBTOTAL:
against said City in cons aptence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appllont/Contractor Date EXHAUST HOOD(W/DICT) , CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Tatum building occupant store or handle hazardous HEATING UNIT(TO IW,"BTU) Date Revel t#
material as defined by the Cupertino Mu Ncipal Code,Chapter 9.1;and the
Health and Safety C°deL$. ioo 25532G)7 HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yea No
Wllltheappllca nt future building ocopantuseequlpment ordevices VFNILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit haeardous air comamhunts as defined by the Bay Area Air
Quality Managementttt2 BOILER-COMPOMPOR 100,000 BTU) r�
❑ Yea No R l00,0008TU) A , ID
�. ]have mad the haza cam materials requirements under Chapter 6.95 of BOILER.COMP(OVE
the California Health k Safety Code,Sections 2550.5,25533 and 25536. I
understand the Ify,heo.padoes not e,rquiyhaves,hiahL usl is my NEW RESIDENTIAL MECH. SQ.FT. P JIM
rnponsiblllty ro notify the ocavpant of the mqulrenpnts which mustMmet G Ff
for to issuance bliss ofOccupancy. -�� (s G
VII Y Uh la.
net or authorize a e ISSUED Bri
_Date IllvV
�/KI
OFFICE COPY