24156 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proed IJentlflatlonPEahITNQ 41 5 6
eullding Address:
/VC
rare scot: one;
CITY OF CUPERTINO6BUILDING DIVISION
Co^dd.?r'.N . _ L1c.No: APPLICATION / PERMIT
Z"'eI BUILDING -MECHAMCAL CATEGORY CONTROLN
Arc a/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ^� 9 T'3 cam. PERMITISSUANCE �jo ❑ O ❑
U. 9 FLUME MECH
LICF.NSEDCONTRACEOR'S DECLARATION
I hereby affirm that l am licensed under prevWonsof Chapter9(commenc APPLIANCMRESIDENfIAL JOB DESCRIPTION
Ingwlth5ectlon 7000)of Divislon3 ofthe Buslnessand Professions Code,and my
eanse lainfull = deflect. �OZZSZ PANES �TL ��
Clcense m LION l tl l ll
Date Contractor 1(
CHITECI' ECLARATION 1201.1000AMPS
re0 Q I understand my plans shall be used as public records. OVER 1000 AMPS a SQ.FT.H.00R ARFA $/SQ.FI.
Licensed professional SIGNS ELECTRICAL x]flnL��A IryL IpIE� D
<L C VY 1 V 1
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
Z s, � IhercbyafErmthat lamexemptfromthe Contnctore Lirenee law lwthe
qq following maven.(Section 70315,Business and Professions Code:M cityor
Fq county which requires a permit W omestruct Mter,Improve,demollsh,or reair TEMP.METER ORIOLE INSF.
Q anystrodore priorto Its Issuance,alsorequires theapplicant fersucb permit toDAT
U File a signed statement that he Is licensed pursuant to the provisions of the TOWER DEVICES JI
340 Contactor.License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRICcion 3 ofthe Business and ProfessionsCode orthat he Is exempt therefromand VALUATION
the balls for the allegedexemption. Any violation of Scotian 7031.5 by any a/N
Q$' applicant fora permit subjects the applicant to a civil penalty of not more than JAIOUTLFTSSWITCHESFTXTURIS VV
flue 1,as owner
nerdelof hepr($500), NEW RESIDENTIAL ELECTR SQ.Ff. STORIES TYPE CONSTRUCTION
7�n a saowner It the property,or my employees with wages ns offered
dole
C < compensation,Business and randthestmctureis at ContrendedorcnseLfor
$�q sale(Sec.7064 Business and Professions Cade:The Contactors License Law
O3F does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself orthreagh his own employees,provided that such
Improvements arc not Intended oroRered for u4.14 however,the building or TOTAL:
Improvement Issold within oneyearofcomplelion,the owner-bullderwill have
t"rden of proving that he did mat build or improve fee purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN _
LJ I,as owner of the property,am exclusively mntradlng with licensed PERMIT ISSUANCE
to construct the project(Sec.7064 Business and Professions Code:
The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA)
builds or Improves therna^, and who contracts for such p(ojeca with
�N(acior(e)licensed pursuant to the contractors Limas Law. FEE SUMMARY
am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,ARRA,COND. SANITARY Y N
OUTSIDE FEES
Owner Date RFCE PT#
WORKMAN COMPENSATION DECLARATION
❑f hereby affirm that I have•redi0re aof consent to aeI mF7%NRES.PER TRAIT SCHOOL IM Y_ N-Inw
,or RECEIPT N
3800,
labbCJ ao(Warken'Compewtlanlnsuanre ora artl(led copythereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARK rM Y N
policy N GAS EA.SYSIFM-OVER 6(EA) RECEIPT'M
fir^ •^Y BUILDING DI VISION FEES
Red copy la hereby fumbhed. GREASE/INDUSIRL WASTE INTERCEPTOR
FEE
-
ertRIed copy b filed with the city inspection divislon.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200171'. Date Recei t#
(Tela section need act be completed If the permit b(arorm hundred dollars
(5100)orless0 WATER HEATER W/VENT•/E,ECTR ENERGY FEE Y_ N
(certify thatInthe personinaofthework for whichthiopermitIs cLroed,
I shall not employ any pecan In any manner so ns to become abject to the WATER SYSTEM/TREATTNC
Wwkca'Compenatlon Laws of Gll(omh. Date PAID
O Z Applicant raDate Recti t#
Z O NOTICETO APPLICANT.If,after making thio Certllateof ExemPHon,you NEW RESIDENTIAL PLMB. SQFE.
Fshould become subject to the Workers'Compeatlun pmvbions of the Labor TOTAL:
W Code,you must forthwith comply with such provisions orthis permit shell be BUILDING
deeed revoked.
d mCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.flim,that there is a construction lending agency for the perform- ELECTRIC FEE
� Z ..on of the work for which this permit V issued(See.3097,CIv.C.) TOTAL: .D
O O Lander'.Name PLUMBING FEE
LLT Lender'.Addrus QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I eadlfythat l haveread this appliallonand patethaltheaboveinformation
bcorrect.l agree to comply with all city and county ardlnancesand rote laws PERMIT ISSUANCE FEES PAID:
>- D, relating to building comtmctron,and hereby authotlae representatives ofthis
?W city to enter upon the above-mentlonedpropedyfor Rupectlonpurpoext. ALTERORADDTOMFCH.
Mr)agree to save,Indemnify and ep harmless the City of Cupedlno Date Recel t#
U agMrMt Rlties,jsdgmentn,co ex erases whlcheraylnanywayaaroe AIRIE&NDLINGUNIT(1010,000CPM) SUBTOTAL: -4
Zal 1 City In(Orae en o ming ItNa rmlt.
AIR HANDLING UNIT(OVER I0,EI0CFM) CONSTRUCTION TAX
SigNature of App! /Contractor to FEQ IAUSTHCKD(W/DUCT) CONSTRUCTION TAX PAID:
IARDOUS MATERIALS DISCLOSURE
Will the app terfuture building occupant store or handle hanrdoud HEATING UNIT 100,000 BTU) Date RLrei t#
materialasdefin by the Cupertino Municipal Cade,Chapter 9AZ and the
Healthye. SafetyCadr,fRlan 25537(.)7 FIFA7INC UNIT(OVER 100,000 BTI1) TOTAL: � O•D
Yes No
Will the applicant fu re building occupant use explpment or devices VENTILATION PAN(SINGLE RESID) ]S WN(b DATE
which emit havadous It contaminsnts as defined by the Bay Arca Air o-Ya (}W� I11�b
Quality Management 1) 7 BOILER-COMP CHIP OR 100,000 RTU)
FSI Yea No AUG2�j (�(�
t haifrnia tech r sCode, reclofirments 2555,2553aChapter6.95 of BOILER-COMP(OVER 100,000 BTU) A2`e 1%2
the ratxrnla Health thi Safety Code,Sections25505,25533have
a tend755atIt
understand that if th building docs net currently have a/enant,that ltbmy NEW RESIDENTIAL MFCH. SQ.Ff.
resp. Itytonatilythe a ftherequlrementawhichmuatbemM
1 b onceo/a rd' t cupamy. CITY Ur kaur Ln i 114V
nercraul agent Datek
TOTAL
ISSUED BY: s
OFFICE COPY