21470 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY T
Building Project Identification - PERMIT NO.
Building Add...: P12Jrie'e1 Oc ( 21470
vreone:
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' CITY OF CUPERTINO-BUILDING DIVISION
C ran e.Name:�y ( ,�tc.No APPLICATION / PERMIT [t, so-qd
L c7l " S �D�I�I.;I� BNLDING-ELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL I
t1-cct/FnRI Ic N
Q'rr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcac _ — PERMITISSUANCE ❑ ❑ ❑ ❑
LICENSEDCONTRACTOR'SDECLARATION
I hereby affirm that l am licensed under provisions o(Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Scc lon700)ot Dtviaion3 ofthe Bustvsaand PmtesdonsC.de,and my
license le In full to.and affect. PANELS
License Clam LI.N
Data ContractorUP TO 200 AMPS
ARCHITECTS DECLARATION 201-ICCOAMPS
qqq otZ l understand my pknssbal be used as public records. OVER 1010 AMPS SQ.FT.FLOOR A 5/SQ.Ff.
d(/ Liwnsed Profeeabvl SIGNS ELECTRICAL 9(no eZOsdo
.4 OWNER-BUILDER DECLARATION Spp-CULCIRCUfT/MISE ``'��JJ
1., F, Ihercbyaffl.that l am exempt from the Contractor's Limew law for the
(.lowing enter.(Section 7071.5,Business and Pmfewlons Code:Any city or gilt{p,MRpg OR POLE INST.
O
county which".I.a permit to rovtmet,alter,Improve,demolish,or repair
any structure prior to Its Issuance,also requims the applicant for such permit to
POWER DEVICES
y'a file a signed statement that he isIicenaed pursuant to the provisions of the
3 se S, Contractor's License Law(Chapter 9(commenctng with Section 7000)of Divi- SWIN,VRNG IDOL ELECTRIC
H�O�p .1mamthe Boston.and Pmfnd..Code)arthat he lsexerept therefmmand
VALUATION
Sr' the breis for the alleged exemption. Any violation.(Section 7031.5 by any Q
«
applicant fora permit subjects the applicant to a civil penalty ofnet=m than OUTLETSSW[TCHESIT%ITIRES U a�,a'G _
Ilvn ndred dotkn(¢SqO. NEW RESIDENTIAL ELECTR SQ.FT. V lu�.JJ
I,as owner of the property, TYPE CONSTRUCTION
�n gw
p perry,orhe employees r offered for
their
a: co peneat0Kan,Businesswill do and P,andthestmdurels em intended License
Lw
O sale CSM70Kto Business aMf property
Code:Widshe CimpHoves themea Law
$ docs not such
.snowy olf rth.g ywhureempoy.,pr nlhereoRand that such OCC.GROUP -RES UNITS
whodoementsaorkhimssded oroughed far s employers,er,the uilding or
Improvementsarenot Intended earofco forwk.If,however, deer ill have TOTAL:
Improvement ls sold within ovyearo(compldloM Iheowner-W Bderwill have
ttaIlurdea of pmving that he did nm build or Improve for purpose ofwk.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with Bernard PERMIT IgSUANCE
contractor to conslmd the project(Sec.7044,Business and Protessioru Code:
The Contrect.re License Taw don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improve,thereon,and who commch; for such p(ojeds with a FEE SUMMARY
cgp¢adpursuant to licensed pursuato the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for this reason
DRAINS FLOOR,ROOF,AREA,CONT). SANITARY Y N
!� Owner Date RECEIPT
WORKINANCOveaccAl te.f,CLARATION ITXTURES-PER TRAP SCHOOL TAX Y N
H, hereby afOrm that I have o lemonle of covens to opythemof(Sa ��.N
rtl L bCj arkere Compevatloninsurancemacertllkd copy there.((Sec. GAS F.A.SYMIM-1 INCA OUTLETS PARK FEE Y N
3800,Ieb CJ
Policy M RECEIPT N
Com any GAS EA.SYSfPhf-0VER4(EA) BUILDING DI VISION Fr.IS
Certtfied copy ls heed with
the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
i edifted copy Is(ledwiththe city Inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
otbe.COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200PT. Date V Recel tic SLo
Qw
hi, dion need not be completed tithe permit ls lor.ne hundred dollars
aI00)orless.J WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent that In the pop performance ny work an as to be. subjermit ct
bl the
I,hail not employ any person f any manner an m to become eubjM to the WATER SYSTEM/TREATING / [��eb
W.rkcan Cwnpenaaaon Law,of California.Date PAID ,`l
O Z Applicant Date Reeei til
Z p NOTICE TO APPLICANT;If,after making this Certiflcate of Exemption,you NEW RESIDENTIAL PCMB._SQFT.
should become subject to the Workers'Compensation Provbiovofthe Labor TOTAL:
CC W Code,you at forthwith comply wlths.ch provisions or this permit shall be
W > dnmed mucked. 13UILDING FEE /
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyatlmthat there is a mvtmdion kndingagenry forthe perform ELECTRIC FEE
Z once fthe work permit la issued(Sec.3097,CIv.C.)oTOTAL:
OO Lender'.Name PLUMBING FEE _
LL H Lendee.Aldress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iwrtilythat I have read thlsappitcati....d state thattbeabove Information
IL i.o. d.I agree to complywith all cityand county ordinances and nate laws PERMIT ISSUANCE F S
>. W relating to building consimcdon,and hereby authorize representativn ofthls
F = city to enter upon the aWee-menlloned pmperty for Impaction purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu penin. Date Receipt
V
g.lost liabilities,pdgments,cost..ad npevn which may In any way a.. AIR HANDLING UNIT(TO 10,00 CFM) SUBTOTAL:
lost t said City 1....q.ence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,00CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUSTHOOD(W%DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding ossa pant store or handle hazaMents HEATING UNIT(TO 10,0)0 BT1p
material as defined by the Cupertino Me nicipal Code,Chapter 9.1 2,and the Date RCCei tq
Health and Safety Code Section 25532(2)7 HEATING UNIT(OVER 10,00 BTU) TOTAL:
❑Yea i1]N.
WN the applicant orfmam building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANfSDA�
which eMthazardous air contaminants as defined by the Day Area Air 1("'
Quality Management District? BOILER-COMP DHPOR 100,00 BTU) .
Yee ❑❑us MA9 6 ?'It)?4havmad the hazardous maledahre m
Ircenle under Cha er 5.95 of BORER-C'OMP(OVER 10,008TUR) Fl
the California I{ealth k Safety Code,Sed Ions 75505,25533 and 25534.I
understand that if the building does not cormotly have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. ,s{
Pdpondblllty to notify the occupant of themquimmante which=at be mat City Cug�Nlnn
or in Issuance of a Certificate o(O=j anry. V4
Owner or authorized agent Date ISSUED `
?DIAL:
OFFICE COPY