21694 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project[do testis. PEILWTNO.
Building Address: 2169419 441
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Owners ame: ^^ p
d —'PACKAl2p 44 -0S3o CITY OF CUPERTINO-BUILDINGDIVISION
con�r c N : APPLICATION /PERMIT
EngineerBUILDINGELFICMCALPLUMBINC-MECHA AL CATEGORY
.1 w QTY ELECTRIC PE M FEE BUILDING PERMIT INFO
Add_ re.a:'�xale�ey�7 Jul rPGe
�nabyrPERMITISSUANCE y IS2T ❑
11
/ LICE.N,I.m c TRACTOIPS DECLARATION - LjJ j/�
1. I ithSacd(irmthatlam Bcenerfthe BuprovLslonsoffeWwsr9de,and a APPLIANCESftESID JOB DESCRIPTION
I ith Section 7000)o(d offeon3o(the Butlneuand Profeulona Codc,and my
Iicenx Is In full fo end d(ett. �L P
Lirense Class_j� ic.P t-
Date Contractor
ARCNITECI'S DECLARATION
ON Oqq 11 1
dente d my p W ,shall be use1d as public s. ER 000 AMPS SQ.FT.FLOOR ARRFA E/SQ.FT.
E�`j LL Prot-fowl +I�"� SIGNS ELECTRICA 003 / 1 }
��6 OWNER-BUILDER DECLARATION SPFCIALCIRCiP `}'
ZF, � 1hembya(firm that Iamexempt from the Contractors License Law for the
following reason.(Section 7031.5,Buslnea and Probsaiond Code:Any city or
O TEMP.MhTER R LEINST.
p4 anystmcounty mprirtoitsch requima Nwameperrrdt to mrutruuimtr,lmpb=tfe suah, rretto
any at rutturetatementshat he
acarsed msuant t the revisions of to POWER DEV
�nE � Ole a signed statement that he b Ilrensed pursuant to the proWloru of the
Contractor's License Law(Chapter commencin with Section 7000 of w0 fn K Pt ( 8 ) SWIMMING 1170E ELECTRIC
1� alan3 otthe Buelneae end Profexiov Code)orthrt heb exempt lhrrc(romand VALUATION
Q the basis for the alleged exemption. Any violation of Sactkm 7031.5 by any ETSSWITCHESFlO ` do
lora permit subjectathe applicant toa civil penalty d nmore than %TURES
M
fyeJiundred dollen(550 . —SQA,
'< Las owner of the property,or he employees with wages r their dole
NEW RESIDENTIAL EL[CTA STORIES TYPECONSTRUCTION
peac.70 n,willdoth.workandions Code;
Tis he Contractors
or offered Lave
O dole(Sec.7016,to alnean vvner Profesof sions Cobuilds Contractors Lirerse law
�$ whdoeodo applylorkbi nrorth=gtywhonempoyees,p eidh thryand OCCGROUP RES.UNITS
whodoem nts am memsen edoroughedowneor .If,ho evert ebuilding
that gor
Improvements memendedpldio.ILhowevey deer iiI have TOTA
Improvement bsWd wlthinoneycaro(complMloMtheowner-buiiderwlll have
to rden of proving that he did not build or improve for purpose ofsale3• QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with limnxd PERMIT ISSUANCE
to construct the project(See 70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
build.or Improves thereon,and who contracts for such ELLER-DRAIN&VENT-
��
cts with a WA )
c15.c m(s)licensed purauant to the Contractor'.License I. FEE SUMMARY
L�I am exempt under Sec B k P C for thin nawn BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date gpCpR Na `
WORKMAN COMP LT9SATION DECLARATION �.Nws� SCHOOL TAX Y N
❑i hereby affirm that I ery t a certificate of consent to pythhnrc,ora RECE97If
certillcateo(Workeri Compemationlnunnre ora certified copythenof(Sec. .I INCL OUTL 5 1 PARK FEE Y N
Policy M i DING DI M
Cram an G EA!SYSI'EM 6 ^�
Y BUILDING DIVISION FEES
ertitled copy is herebyfamished.the city GR E/iNDUSIRL PLANCHECK FEE
Certified copyb(fled with the city Inspection divisions.
CERTIFICATE OF ID(EMPTION FROM WORKERS' GR PAID f� /r
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.20CFT. Date Rech t#
Qhb section need not be completed lithe permit Is for hundred dollen
0110 mmfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]sent thatlnthe person in any mannhe er so as t cern permit is bayed, —
Ishall net employ any person In any manner at u to become subject to the WATIRSYSTEM/TREATING 1 1�a
Workers Compensation Lewd of Glitornla. Date PAID
O Z Applicant NEWRESIDENTIAL PLMB. SO.F7. Date Revel IN
Z Q NOTICETO APPLICANT:If,after ma king thisCertifirateot Exempit.n,you
C` should become subject to the Workers'Compensation provisions of the Labor TOTAL
y Code,you at forthwith complywlth such provisions orthb permllnhall be
W > deemed revoked. UI
GCONSTRUCTION LENDING AGENCY SEISMIC FEE
a FEE _1151
IfierebyafOrmthat them is.construction lending agency for the perform- ELECTRIC FEE
Z anreuftheworkforwhlchlhbp.rMtbbeued(See3097,Civ,C,I TOTAL:
U all
O I.enderb Name PLUMBING FEE
LL F IantenAddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcenfythallhavereadiRbapplintionanddakethattheabovelnformafon ��
6 Is Garrett.Iagrcetocomplywlth all cityand countyordlnmen end state]awe PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorise reprexnbtivea of tM1b
Z city to enter upon the a bove-mentioned property for inspection purposes. LTERORADDTOMFCH. Z erg•
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recel til
against liabilltics,judgments,ncentsand expenses which nuyi..ey..ya.e AIR HANDLING UNIT 17010,000 CRM SUBTOTAL:
against said Cm
City In nseque/xof the grant ing of this permit.
W /y,� AIRHANDLINGUNIT(OVFRIO,000CPM) CONSTRUCTION TAX
Signature of Ap cant/Contractor Date EXHAU5'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanbtore or handle hazardous HEATING UNIT(TO 100,000 STT!)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reedt
Health and Safety Code,Syt11on 25532(a)7 HEATING UNIT(OVER I WOM BTU) TO
❑Yes ���(1nto
Will the applicant re,building occupant use equipment or devices VWIILATION PAN(SINGLE RESID) ISSUANCE DATE
which rent hazardous air contaminants as defined by the Bay Area Air
• Quality Management Dg!;? BOILER-COMP 0IE'OR 100,000 BTU)
4Yes No
h.va read the hazaraous materials requlrernenhunderChapter6.95 of 501ER.COMP(OVER100,000 BTU)
the California,Health k SafetyCode,Scctiom 25505,75533 and 25534.1 P A D
understand that lithe building does not currently have a tenant,that It Is my NEW RFSIDENIIAL MECFI. SQ.I•T.
r nsibility to naifytheo=p.rat.(therequlnmenlswhichmuntbemet ` ,
p r bsuanceo Certs t o(Occupan_ I^,S rs f� LC y E - 1992 a�
Owner or authorized agent I Data ISSUEDDVI ' of r ,v a
TOTA.:
OFFICE COPY