21848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proect Identification _ PERMIT NO.
Building Add.,: - /�ai �9 /�
of//ODD 9,414. 0 Die•j 6071,40 Ge • x/18 1/ G I 8 `8/
TTWners oma: )�� � one: A A
40"11 �4 . 2S;7-63/A CITY OF CUPERTINOLBUILDINY DIVISION Q
Contractors Name: Lie'Npjs APPLICATION PE MIT
*S5 �+ BUILDING-MFICTRICAI,PL ECHAMC L CATEGORY I CONT12
.'Architect/Lnglneee Lk. �V
�'/ NNo:a: �Q'In ELE RIC E MIT E BUILDING PERMIT INFO
Address: le) / PERMIT ISSUANCE :� (� ❑ ❑
PLUME MECII
LICENSED CONTRACTOR'S ECLARATION y/J
I hereby affirm that lam Licensed under provisions of Chapter9(comrumc AFI`UANC RNTTAL OB DFSCRII'TION
ingwilh Section 7000).MW.ion3ofthe Busindssand Professions Code,and my •T,
license is In full force and effeet. T. I UUP
License Class Llc# 1
Date Contractor`\�1(� L`
ARCHITECTS DECLARATION AM
ne O I understand my plans shag be used n pubbc remrds. O ER 1000 SQ.FT.FLOOR AREA $/SQ.Fr.
E o Licensed Profeaslonal SIGNS EL TRI
�< OWNER-BUILDER DECLARATION SI'ECWLC T u15C
7 I hereby afflrmthat l am exempt from the Contractors License Law.,the
QQ pp following lemon.(Section 7031.5,Business and Profession.Code:Any city or
county which requires a permit to construct,alter,Improve,demolub,or repair TEMP.M RI'OLE INST.
anystrocture prior to Its Issuance,also requires the applicant for such permit to
O U file a signed statement that he u licensed pursuant to the provisions.f the POWER ICES
u, Contractor's License law(Chapter 9(commencing with Section 7000)of Divi-
�05 sion3 of the Business and Professions Code)or that he u exempt therefrom and S NG POOL ELECTRIC VALUATION
the bash for the alleged exempllon. Any violation of Section 70315 by any
�$ hot—
applicant fore permit sub' thea Ilcant to a civil rat of not room than OUTLETS-SWITCHES-FIXTURES R subjects PP penalty s OC9O.C) v
five hundred
nerofthepr. NEW RESIDENTIAL ELECTR FT.
�n ❑I,as owner of the property,or my employe.with ween as their w �' SLUR[ TYPE CONSTRUCTION
t compensaHon,wiild.lhe work andthe stmcturebnot intended.r offere or '
5 O
s'
Is 7044,Business and Professions Code:The Contractor's Lire ]aw
[ $$ does not apply to an owner of property who builds or improves thereon,and
0. whodon such work himselforthrough his own employees,provided that such OCC.GROUT' RF5.INR5
improvements are not Intended orofferedforsale.If,however,thebuilding or / (� r' L:
improvement wn
lssold within oneyearofcoenpletion,the oer-bullderwill have
�
t1tben of proving that he did not build or Improve for purpose.fwlW. QTY, ' PLUMBING PERMIT FTAOD ZONE APN
LvJ I,as owner of the property,am exclusively contracting witb Emoted ppg),ffT ISSUANCE
com.cto.to construct the project(Sec.7044,Business and Professions Code: - b
The Contractor's License Law does not apply to an owner of property who AL DRAIN&
Wilds or Improv. thereon, and who contracts fee such ju jects with a - ,
cl5ador(s)Licensed pursuant to the Contractor's License Law. IX I {; FEE SUMMARY.
LI I am exempt under Sec B&P C for this ronann '
L71 OUTSIDEFEES
_ DRAINS RROOF,ARCA,GOND. SANITARY Y N
Owner Date RECEIPT p
OR I PEN ION DEC to
M URES`ERTRAP' SCHOOLTAX Y N
QI hereby affirm that r have a Insom to of consent to opythemsd or a RECEIPT N
.00,Lab o(Workere'Compensatl.nlwurana oraartBlCd mpgthercof($.. GAS EA. -1 INCA OUILES
3800,Lab C.) PARK FEE Y_ N_
Colmcyan GAS EA.BY -OVER 4(EA) RECEIPT M
Y BUILDING DI VISION FEES
cm
copy u berebyth the city
GREASE/INDU WASTE INTERCEL`TOR PLANCHECK FEE
�Certi(Ied copy la(fled with the city Wpe M.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID' Lj
GOMPFN$ATFONINSURANCE Il
(This section need net be completed lithe permit is(Drone hundred doldollarsSEWERSANHARYSTD EA.200E-1'. Date Remi t#
($100)orless3 WATER l[EATER W/VENT/ TR ENERGYFEE Y N_
[certify that1.the rforperson
an as to hehis mn,perout is
subjclased,
I shall not employ any person In any manner n u to become subject to the WATER SYSTEM/TREATING
Worken'C.mpen.atlon Laws o(GII(ornla. Data PAID
C' Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. -Date Reset t#
Z O NOTICE TOMPLICANT:It,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be $ DING
deemed revoked.
FEE
Sp CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there u a construction Lending agency for the perform ELECTRIC FEE
UO Lender's hN,�.rkfor which permit (Sec.3097,Cis.C.) IV N�T PLUMBING FEE
LL F Lenders address MECHANICAL PLFRMIT E MECHANICAL FEE
O W Iunity that have read this application and elate that the above Information Q
6
reIs lating
gt building comply with all ndtyand
yautho rdlnan.sand
ativesMate laws IT ISSUANCE FEE P-sS AIDy 67•�^
} W relatoenterupont eabov N.ryandheroby authorize represenpurposof this
Z
city Wenteree to ue,indcundly aned property for inspection purposes. AL OR ADD TO MECH. Date Recent#
V _
(We)agree to seve,InddmNfy andk.peharmless which the City of Cupertino P
against Liabllltles,ndgmenuenceoand expenses which muylnanyway accrue AIR NDLINC UNIT CIO 70,000 CFM) SUBTOTAL:
against dCity in ronsequen.of the gaoling of this permit.
AIRHAIRUNG(NIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST I D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or futurebuilding occupant atom or handle hazardous HEATING (TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the -
H.lthand Safety Cale Sectlon25532(a)? HEATING UNIT( VER 100,000 BTU) TOTAL:' 3
❑Y. T__No
WdI the a ppBomtoPture building occupant use equipment or d evices VENITLATIONFAN NGLERFSID) I UQjCE.DATE
which cent hazardous air contaM.nts as defined by the Bay Area Air A v
Quality Management District? BOILER-COMPOHPOR ,000 BTU) '
4Yn (1�No
havam.dtheh an7ousmateriabrequirementsunderChapter6.95of BOILER-COMP(OVER 100, U) APR 17 1992
the GlLfnua Ii.lth&Safety Code,Sections 25505,25533 and 25534. 1
und.t.0 dthatlfthebuildlngdoesnotcurmntlyhaveatenangthatitismy NEW RESIDENTIAL MEal. SQ.FT.
responsibility to noilfy the occupant of the requirements which must be ,t ,/
prior to issuance of a Certificate of Occupancy. C1IY I)F Vt.letn I B4U
Owner or authorized agentDate ISSUED BY:�` V
TOTAL:
OFFICE COPY