21704APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building 11dd6 lollve K —i -3.YC Plan l gi-T
PERJd1TNO.
- 21704
ame: /' erne
fa Q Lei fi'�(1 TC.
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
BUILDINGELF nUCA PLUMBING -MECHANICAL
A A
/_ -Z .�. 9�
C ceName: ueN:
CATEGORY
CONTROL•
A Iter/En' yy
Q1Y ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
PF2th9iISSUANCE
LICENSED CONTRACTOR'S DECLARATION.I
I hereby affirm that l am licensed under provisions of Chapter 9(commenc
ing with Section 7000) of Division 3 of the Bminos and PmfeesleaCede and my
u ".. II=�l I.. y " OD 9 �'
APPLJANCESRE9DENIIAL
)OB DESCRIPTION
F• D 1,11 L
P""°s
Date Contractor
301-1000 AMTS
' ARCHITECTS DECLARATION
I understand my plans.hall be used as public mcvds.
OVERI"AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I a. exempt from the Comrade,. License Law for the
following reason.(Satlon 701.5, Buslnca arW Pmfealon, Codr. Any dty or
oauntywhichrequlrt,aper ttocomtmMalter,lmpmve,demollsh,ormpair
�� SU L!p
r 1
1
V.4q
`
SPECIAL CIlZCNT/MISC
TEMP M=ORPOLE INET'.
anystmd mprieatolbis ame,al mquimiheappllantforsuchper tto
file a shed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
/
SWIMMING BOOL ELECTRIC
OUTLETSSWITCHESFIXIURES
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
slop 3 of the Business and Prom.lens Code) or that he is exempt therefrom and
the basis for the alleged jeemptbn. Any ttola ivi of Sectionpenalty not m re any
the applicant to dvil penalty of rad rrorttHn
•reliant fora pedoll..
VALUATION
C/ / 9� .
!!!
NEW RESIDENTIAL ELFCTR SQ.Fr.
($50jecta
five 1, as neroft(f5pm
1, as owner of the property, or my employees with wages a there sole
STORIES
'M'E CONSTRUCTION
will Bothe work and the structureh not Intended or offend for
ole
&c. 0K alnea and
sale (See appy Code: The C Llxnsc Taw
to rope ty
f propertyimproves
whodotapplytork owner ofthroug hiswho nWilds
who a k himself mporimprwvided eoRand
provided that such
hhownemIf,
OCC. GROUP
RFS.(1NRS
ove, nt. am ed orough
how,
Improvementsaonor intendedoroffeco pleioe.ILh nor-pthebulldlngve
Improvement lssold within oncycarofcompleHagtheowner-bu8derw111 have
TOTAL:
thy. rdrn of proving that he did not build or Improve for purpose of sale.).
Lj L as owner of the property, ty,am exclusively =trading
mntacteato constad the project (Sec. 701141, Busnas and PrdalOns Cade:
e
QTY
I E
p E
FLOOD ZONE
APN
The Contractor's Lt... Taw does not apply to an owner a property who
Wilds or Improves thereon, and who contrail, for such projects with a
rag dors) licensed pursuant to the Contractors License Law.
LJ 1 am exempt under Sec B 4 P C for this reason
A D V - IFIL
FEE SUMMARY
BACK FLOW PROFECT. DEVICEa(2,
OUTSIDEFEES
D
.SANITARY Y_ N
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirmorker that I have a Insurance
nfra c of consent to opythe of or .
Workers Cempinsatlonlnsuraneaeaaartlfled copythemcofCrzc.
3800,Lcerifficte Lb
3800, Tab CJ _
1'o11ry N
FE(gUgps PER TRAP,
SCHOOL TAX Y_ N_
RECEQ'r N
GAS EA. SYSTEM -]INCA OUTLE7S
PARK FEF. Y N
PT N
Com
GAS FA. SYSTEM-0VFR A (EM,
DNG DIV
BUILDING DIVISION FEES
Codified copybhereb/fumlahed.
CedBied copy ls fl4d with the dty Inspection division.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANGHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(This sedbn need nab completed if the permit ls forone hundred della.
PAID
Date Recei tf(
SEY✓FR-SANITARY-SCORMEA 200Fr
WATER IiFATER w/vFxr/ELECTR
ENERGY FEE Y_ N
PAID
($100)ealess.)
I mAlfy that In the performance of the weak for which this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the
Workers'Corepen,ation Laws of California. Date
WATIR SYSTh.,1/1RG17NG
Applicant
NOTICE TO APPLICANT: If, after making this Certificate Of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Remi t#
NEW RESIDFMIAL PLMB. SQFr.
TOTAL:
Code,younmstfonhwithmmplywithsuchproWlomorthisperMtshallbe
deemed revoked.
BUILDINGFEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hembyaffimathat then ls a construction Lending agency for the prefornv
ane, of the work for which this per t is Issued Lsec. Som, Cm. C.)
TOTAL:
ELECTRIC FEE
lender's Name
PLUMBINGF- -
9
Lendersnddma
ImdlfythatIhavereadthbappB tlonandnatethattheabove Information
lscomest.I.greemcomplywithall dtyand countyoNinanaaand A.tel.w,
relating to building constadlon,saad hereby authorize representatives of this
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
F•
city to enter upon the above-mentioned property for Inspection purpose,.
(We) agree to save, indemnify an d keep h.mdea the City of Cupedlro
ALTFRORADDTOMECH.
Date R2CC1 IN
P
SUBTOTAL:
against liabilities, pdgmems.mat ... d e.penses which may lnany way accrue
against said City In onn�he granting of this Innis,
/yam/
AIR HANDLING UNIT 1717010,000 CFM)
—MR
R HANDLINGM'I
NG T (OVER IO,000CFM)
CONSTRUCTION TAX
,
Signature of AMeant/Contra& T -I1 Date
IXHAUSTHOOD(W/DICT)
C ON T PAID:
R X
�y
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNI'T(TO 100,0)0 BTI.
Will the applicant orfutum building occupant store or handle havrdous
materials. defined by the Cupertino Municipal code, Chapter 9.12, and the
/ ate Reeef IN
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
(,a
Iiealthand SafdyCede Secti.e255320)?
❑ Yn M No
VENITIATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devies
which emit hazardous air cont.mlant, a, deflned by the Bay Arca Air
BOILER -COMP 0HPOR 100,000 BTU)
Quality Management District?
4Yes No
have read the hazer s materials requirements under Chapter6.95 of
LAM
BOILER-COMP(OVIR 100,00081 U)
the Gliferma I leallh A Safety Code, Sections 25505,25513 and 25534. I
ptj] 1.a&
NEW RMDENDALMECH. SQ.FT.
understand that if the building does net currently have a tenant, that it is my
.�E
.ponsibilityto notify the occupant of the mqulrementsw ich must emet
prior m iamnm of . Cedlflcatc of Occvpanry.
-
C 1 L I ti 1
(! ,1f
ISSUED BY:T
�_4
Owner or auth Tired agent I
TOTAL:
OFFICE COPY