20708 APPLICANT TO FILL IN-INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ert Idemllkatlon PERb1ITNO.
Build ing Address:
[j O 1 O V
9
ners ams: one:
CITY OF CUPERTINO-BUILDINGDIVISION
dor'a Name: Lic.Nn: APPLICATION /PERMIT UJ
., DINC-ELEM
CTRICALPLUMBING-MECHACAL CATEGORY CONTROLY
Lk.No: BWL
Archi /En eer. �eu /
- -tib QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PEIWTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION tg� Fit
I hereby Bcenmd under Busine provisions of Chapter Codc andme- AI'PI.IANCESRESIDENML JOB DESCRIPTION
Ingwith Sedlon7 )of DlWelon3o(MeBuslnessand ProfneloneCode,and my
license le in oreemd feat. ,/ PANELS a 1\I I,, Fr*
Licanae CL. .M • �/}.-i-J V� 1J LyY/U 9
Date _ Contrado
ARCHITECT'S EQa ATIO 701-IODOAMIS
ofO I understand my plana shall W used as public records. OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Profesalarul SIGNS ELECTRICA
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
Zs' IherebyafOrm that l am exempt from the Contnctor'a Licenae Law for the
O .. following reason.(Section 70315,Business and Prolessloma Code:Any dtyor 7Eb1E'TFR OR EINS .
p; 1' countywhkhrequresapemdttocoretaud,atter,Wpmve,demlWh,ormpalr
rLv d
� 8 anystruurepdartoltsissuand,alsorequlresthe applicant for such permit to
DEW file a signed statement that he U licensed pursuant to the provisions of the SWOd
O O� Conlrectora License law(Chapter 9(commencing with Section 7000).f Divi-
i.,� S slon 3 ofthe Buslnosand Pmfessloru Cade)orthat he is exempt therefromand _ C F7.E VALUATION
6 5
the basis for the alleged exemption. Any violation of Section 7m15 by any OUTLETS TCHM IS
applicant fora permit subjects the applicant to a civil penalty of nor more than
five hundred dollars($500).
�n ❑1,as owner of the property,or my employees with wage es Ihek sole NEW D AL .FT. STORIES TYPE CONSTRUCTION
compemation,wllldothe work and lhestmcture is;not intended or offend for
0 In(see 7014,Business and Profean oro Code:The Contractors Ltd.law
$$ doesnotapply to an ownerof propertywho Wilda or lmproveethereon,and OCC.GROUP RES.UNITS
daessuch work himself or through his own employees,provided that such
Improvements are not intended oroffered formic.If,however,thebulldingor TOTAL:
improvementissold within oneyearofcompletlontheowner-bullderwlll have
tlapuden of proving that he did nor build or Improve for purpose of sale.). QTy, PLUMBING ER IT FEE FLOOD ZONE APN
L j L as owner of the property,am exclusively wntrading with licensed I'F1tM1T.LSSIIANCE �s�
contractors to construct the project(See,7DK Business an
Prolessloru Code:
The Contractor's License law don nor apply to an owner of property who
Wilda or Improves thern, and who contracts for such ptojecd with a ALTER-DRAIN (EA) s OQ
cJILLra ctor(s)licensed
FEE SUMMARY
pursuant to the Contractors Llcan.e Law.
LJ I am exempt under Sec. B h P C for this maaun BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY - Y N
Date RECEB p
❑I WORKMAN COMPENSATION DECLARATION pIX7URpg PER TRAP (� SCHOOL TAX Y_ N
here
by afford that I have•certificate of consent to cal(-mare,ora c RECEIPT M
mdiflrate of Workere'Compewatlrn lruuranoe oracedl(Ied copy therer((Sec. GAS F.A.9YSTEM-11NC4 OUTLETS PARK FEE -Y N
3oik Lab CJ
Pam Rry y J�+ �S�UtJ C'� I'�O GAS EA.SY9CEM-OVER4(EA) BUILDING
RECEIPT#
C�anygci P BUILDING DI VISION FEES
Cedlfled copy V hereby(umbhed. GREASE/INDUSfRL WASTE INTERCEPTOR PI.ANCHEGIC FEE
Cerlified copy as filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION ATION INSURANCE SEWER.SANITARY STORM EA 20OF 1' Date Recei t#
IThlsnedWn need radd be coo completed tithe permit V(Drone hundred dollars
($10 certify
that
In (NATER HEATER W/VENT/ELECTR ENERGYFEE Y N
(certify thatothe person in anftheworkaurwhkhco eemdtcis loved,
I shall not employ any person In any manner at n to become subject to the WATER SYSTEM/TREATING Workers' mpensslionLaws ofGll(om6. Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SOFT'. Date Recei tN
Z0 NOulCETOesubjet to
makingthisationlpru of Exemption,you
should become subject m the Workers'Camperudlcan prov4lom of the Ghot TOTAL:
N
Code,you=at forthwith comply wllh&uch provisions orthis permit&hall be U
LU > deemed revoked. LDING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afOrmthat them is a romtmctlon lending agency for the perform TOTAL; ELECTRIC FEE
a a work(or which tpermitpert b Bound(See 3097,C1v.C.) v�
V O lendersndrr's Name PLUMBING FEE ��
LL I— Lendne.Addmae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lmdifylhatl have read this appliationand statethattheabovelntomutlon q.,
1 Iamrted.I agreeto comply with all cityand countyordlnances and date laws PERMIT ISSUANCE -(CID FEES PAID:
} relatinglo Wildingmmtmdion,aMd mbyautho .0 p..a tivnofthls
U) city to enter upon the above-mentloned property for bupWion purposes. 7 ALTERORADDTOMECH. iob eCCI Date Rt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino - P
against Itabllltlea,Iadgmants,coeband expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
ago bntsaid City In mnerp}enca of the grant ing at this permit.
��jA AIR HANDLING UNIT(OVER IQODDCFM) CONSTRUCTION TAX
Tnatum of p i / onlredor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stomor handle haeallous HEATING UNIT(TO 100,ODO BM Date RCCCI to
maMrlal as dented by the Cupertino Municipal Code,Chapter 9.17,and the
I leallhand SafetyCodIon 7S537(a)i HEATING UNIT(OVER ID0000 BM TOTAL: CID
❑
Y. N6rio
VIlllheapplicanto tore building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which ertd haaardous air rontaminanb a.de0ned by the Bay Area Air
Quality Management DTs ricv BOILER-COMP OHP OR 100,000 BTU)
Ye. No
Ihavereadthehara ous maleriabrequirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25SQ5,ZSS33 and 2534.T
understand that it the building does not curmatly have a tenant,that it is my NEWRESIDENTIALMECA.
reaparoibiley to rad lfythe panto(the mqulremente which moat be and JUL h V d
prior loi race Ce ate of Ocmpanry. ' 9
nerd o ce agent Date
TOTAL: ISSUED
OFFICE COPY