19484APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'en Identification
Building Adds
PERT NO.
MIkL:hCL 19484
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CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
BUILDING-Ct.ECTRICALPLUMBING-MECHANICAL
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c°�ytr}�n raNa^e//J�p ��J1Q k. o:
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CATEGORY -
CONTROL N
Architect/Englmer, LIc. No:
Q ELECTRIC PERMIT FEE
BU ILDINGPERMITINFO
Address:
❑ ❑ ❑ INTI
/I—�}.
TISSUANCE
LICENSED CONTR under rDECLARATION
I Mreby affirmdut lam licensed under provisions of Chapter9 (common
ILilnceerse I. ct1on7000)oanfdeffecn.
icen Mss Lk.N 3eflhegudnaasand ProfesalonaCode, and my
.in Contractor
ARCHITECTS ECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby affirmtfutlam exempt fromtheCnmractor'sLkensa Law /ar the
fo0owing reason. (Section 7031.5, Business, and Profeulom Code: Any city or
countywhkhrequUe aper ttommtmd,altepimpmve,demolbh,orrepalr
any structure prior to Sea isnuance,abo requires theappllcent forsuch permit to
file a signed statement that he V licensed pursuant to the provisions of the
Contractor's Llceme Law (Chapter9(mmmerfng with Section 7000) of Divi-
sion3 ofthe Budnessand ProfesalonsCode) orthat he is exempt therefromand
the bests for the alleged exemption. Any violation of Section 7031.5 by any
Applicant for a permit subjectsthe applicant to a civil penalty of net nnre than
five hundred dollars ($500).
01, as owner of the property, or my employees with wages as, their sole
compensation, willdolhe work and thestructure is not intended or offend for
Asia Ike. 7044, Business and Profesalom Code: The Contractor's Limme Law
does not apply to an owner of property who Wilde or Improves Sharron, and
whodoessuchwork htrnselforthrough hisownempl°yms, provided thatsuch
improvements am not Intended oroffered forsale, I( however, thebuildinger
Improvementfasotd within omyearufmmplellom theowner-bu0derwel have
tl)!urden of proving that he did not Wild or Improve for purpeae of sale.).
u L as owner of the property, am exclusively contracting with licensed
conlracmri to construct the project (Sec. 7044, Business and Professions Code:
The Contractors License Taw does not apply 10 an owner of property who
builds or Improves there
Won, and who contracts for so& p(ujecte with a
co�I(acbm(s) licensed puratiut to the Commerce. Llcensa Law.
u I am exempt under Sec. B k P C for this reason
ANCFSRESIDENfIAL
JOB DFSCRI'TION
201-IODDAMIV
OVER 1000
5Q. FT. FLOpppOR AREA h
J{�1(.( ✓t�
/'-i-�
r� / �,I,�
I - / �� f I 't'
-/` ,�J 1 t
xJ r (iJ
S/SQ. FT.
t
t, tv
V
SIGNSELFLTRICA
SPECIAL CIRCUIT/MI
T
T�p'MEIPR ORI'OLEI
POWER DEVICES�{�l
SWIMMING POOL ELECTRIC
OUTLETSSWITCHMFIXIVRES
VALUATION
.
NEWRESIDENTIALELECTR _SQ,
STORIES
TYPE CONSTRUCTION
-
TOTAL:
PLUMBING PERMIT FEE
OCC. CROUP
RES. UNITS
FIOODZONE
APN
PERMIT ISSUANCE
-
LTER-DRAIN kVENTWATER (EA)
FEE SUMMARY
BA FLOW PROTECT. DEVICE
FEES
GRAIN ROOR ROOF, AREA, COND.
FIXTIIRF_S TRAP
SANITARY Y N�
RECEIVE N
Owner Date
WOR"AN COMPENSATION DECLARATION
❑I hereby affirm that I have a care fiate of consent to self- Insure, ora
mrtiflateofWorker CompemetionimuranceoracertI ied copytherrnf(Seec.
Policy#800, CJ 02�, ,�/r x_-�I g CI 'd...
Com! WV �d
Com env
SCHOOLTAX Y_ N_
RIxEI NN
GAS EA. SY-11NC,60UTLETS
PARK FEE Y N
RECETTN
GASFA.SYSIEM- R4(EA)
- BUILDING DIVISION FEES
,[Certified copy is here mralshed.
Codified copy Is filed with the city inspection divdston.
CERTIFICATE OF Cs(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssactlon need not be completed lithe permit a ferom hundred dollars
(1100)or leu.)
I certifythat In the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner so as10 become abject to the
Workers Compensation Laws of California. Dale
Applicant
NOTICE TO APPLICANT: to
after makingthis nation ro iof sons of the Labor
Code,shoulyou becctmesubject Ico Workers Compemrtionprovhis per theail be
Code, you roust forthwith comply with each provisions orthls permit shall be
dMrrlefl MVOked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there V a construction lending agency for the perform-
arm of the work for which this permit Is Issued (Sec. 3097, Cly. C.)
Lender Name
Lender's Addreas
1 mrtifythat I have read this application and statelhat theabove Information
Isco1. I agree to comply with all city and munlyordinanceaandstatelaws
relating to bu iding comtroction, and hereby authorfu representatives of thio
city to enter upon the above-mentioned propertyfor Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of CvpeNno
agaWt Wbllltles,}adgmenb, coatsand expenses whlchna Inanywayaccrue
.gal^�t J(flty in consequence of the granling of this pe IL !�
Z �— ZS/ / D
CREASE/INDUSIRLW INTERCEPTOR
PLANCHECK FEE
PAID
Date RC i t#
GREASE TRAP
SEWER-SANRARY-STORM G. FT.
WATIIt FIFATER W/VENT/ELECTR
ENERCYFEE Y N
PAID
Date Recei tp
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. FT.
-
rs�_
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE /-Z
FEES PAID:
'
ALTER OR ADD TO MECH.
Date Reeei tk
AIR HANDLING UNIT RO 10,000CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
_ "
Signature of Applicant/Contractor IData
HAZARDOUS MATERIALS DISCLOSURE
Will the appliantorfumre building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter9.12t and the
Ileallh and Safety Code Sectmn 25532(a)7
RYes r] No
III the applicant or future building occupant use equipment or devices
which colt harardous air contaminants as defined by the Bay Area Air
Quality Management Di.td&7
4Ym Ne
have read the hazerAaue Code, Se tmqu 0.2menb under 5533 AndChapter 25534.1 of
the entaorn la a le.Itht If the
A Safety Code, of cum 75505, have A t sad 75534. 7
a rreluiremvea tenant shat Remy
undentand yton notify the ingocc dans of
responsibility e o fa Cehe accm of Ocf the rrqulrcments which moat be and
prior to Issuance of a Cedificate of Occupancy.
a(HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT CTO 100,000 BTU) a�b
Date Recei tp
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VW17LATION PAN (SINGLE RESIDE
19kJUDDATE
to z1 199U
City Of rime BO
•f
ISSUED BY L/1'f//•w Slot �� n ,t '
9011,131 MP C31 IF OR 100,000 BTU)
BOILER COMP (OVER 100,000 BTU)
NEW RESIDLNTIAL MECFL SQ.FT'
Owner or authrrlud agent Date
TOTAL:
OFFICE COPY