20696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PERMIT NO,
BnfdilgiA3, d 20696
ADATE
3-/ CITY OF CUPERTINO-BUILDING DIVISION �D
Co an°r Name: Lie.Noe APPLICATION / PERMIT
Ambltect/Engineer. Lic N. BL)rLDINGELECMCALI'LUMBING-MSCI IANICAL CATEGORY CONTROL p
QTY ELECTRIC PERMIT F E BUILDING PERMIT INFO
Address
❑ I� ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE u
ed
er
I hereby a
b frmthatlam ��1F- dtYprovisions olChapter 9(mmmmo-
APPWAN
CESAESIDENAL
IngwlthiofiW=30ftheBuslnmandPro/ssionsCodendmy JOB DCRE'IION
lcenseairsNufameadeffePANES
License2Llc.p 4 `A
Data
"• -D/ aamura o
ARCHITECPS D CLARATION
201-1OW AMPS
qO I understand my plain shall be used as public wounds. OVER 1800 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
M O b Liceneed Professional SIGNS ELECTRICAL
6 ° OWNER-BUILDER DECLARATION SI'ECULCIRCUIT/MLSC
e. Z I herebyaffirm that lam exempt fmm the Contractors License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
Frcounty which requiresa permit tocenswct,alter,Improve,demolish,orrepair TEMP'METEROR POL NST.
.a any structure prior Wits bb
suance,ao requirealheapplicant for such permit to
t°K U file a signed statement that he Is licensed pursuant to the pmvedom of the POWER DEVICES
�Gµ Contractor.License Law(Chapwr9(commencing with Section 7000)of Divi- SWIMMING L MCL
f;•�O� sion3 of the Business and Prefeselorm Code)or that he b exempt thawfromand VALUATION
the basis for the alleged exemption. Any violation of Section 703LS by any
papplicantfor a permit subje¢s the applicant to a civil penalty of not nnretban OU7i-EIS TCHFS'
five hundred dollars($500), NEW DENTfAL EL
7 I,as owner of the property,or my employees with wages a.their sole �.FL STORIES TYPE CONSTRUCTION
C t compensation,willdothe work and Nestmcturebnatintended or oflcredfer
5 ,n sale(Sec.7060,Business and Professions Code:The Contractors License Law
�5$ don not apply to an owner of property who builds or Improves thereon,and
Who does.uchworkhlnvelf orthrough Msownemployee.,providedthatsuch OCC.CROIJI' RIS.UNITS
Improvement.are not Intended oroffemd for sale.I(howeveq thebuilding or TOTAL,-
improvement issold withlnomyearofcompleion,lheowner-bullderwlll have
0ILL,unden of proving that he did not build orimprove for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
caunctors to construct the project(Sec,7064,Business and Professions Code:
The Contracture License Law it.was apply to an owner of proparty who
bup1,TER-DRAIN h VENT-WA1TR(EA)
ilds or improves thereon, and who contrafor such pgojeRs with a
,�5BTactor(s)licensed pursuant to the Contractor's License Law. RACY FLOW PROTECT.DEVICE FEE SUMMARY
cc
LJI am exempt under Sec B k P C for this reason
. Owner Date DRAINS MSYSfEM-OVER
OR ROOF,AREA,GOND, SANITARY RECEIPT.
WORKMAN COMPENSATION DECLARATION FIXTURES- R TRAP SCHOOL TAX Y N
01 hereby.flims that I have o lwaa rate of consent to apytheelf.Wsem,(S a
3800 La ofWorkns Compevatlonlmurannoracenifkd ropytherrof(Sec. RECEIPT
3800,Labe . r tri n �� (/ ^ TEM-1 INC.60lIILEIS PARK FEE Y N
1'oliq M Wli�' O C RECEB'I'M
Com anv Ifo TEM-OVER4(EA) BUIL DING DI VI SIONFEES
[feertlnd py hereby(umbad. USIRL WAS[EI EProR PLANCHECK PEE
rcl Certifid copy ufiled with the city inspection division.Y� CERTIFICATE OF EXEMPTION FROM WORKERS' P PAJDCOMPENSATION INSURANCE(Thlsiurion need not becompleld B the permit bforonehundred dollars ARY- EA.HAFT. Date Recei t#
(S10WorfWATER IfEW ENERGY FEE Y
Inify performanceth
ceat In the performance of the work for which this edATERENT/ELECTR this permitbaa
, N_
1 shall not employ any person in any manner so as to become wbject to the
Workers Compensation law.of GBfomla.Date WATER SY TREATING PAID
O Z Applicant
Z NOnCETOAPPLICANT:ILafermakin thb CenBlcateof Exem ion, NEW REST ALPLMB.
_ p sQ.FT. Date Recei t#
u
should become sub' to the Worken'Com % .
W~ N Code,you..at fon hwith comply withiewh provide.or this permit shall be TOTAL:
> deemed revoked. BUILDING FEE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby,ffirmthatthem barorum ion lendiogagency fmthe perform- rornl: SEISMIC
FEES
0 ance of work which this permit is Issued(Sec.3097,Civ.C.)
V _ Under.Name PLUMBING FEE
0 F- ender.Address Q'CY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfythatlhave rcadthbapplicationand statethattheab°nae ln(ormatlan
S erorsext.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building comtruRlon,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for Wpectlon purposes. ALTER ORADDTO MECH.
V — (We)agree to save,indemnify an d keep harmless the ity of Cupertino Date Receipt#
agairut bilities,judgments,rortsand expenses which may anywayaccme AIR HANDLING UNIT(f010,000 CFM) SUBTOTAL,
agai i In con aryuAnm of the granting of this a It
_ DDDDl�/'/Jl.. z��� AIRHANDWNGIJNTf(OVER If0DOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUC7nON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) D fb0 Date
material as defined by the Cupertino Municipal Code,Chapter 9.B,and the Recej t#
IIealth❑Yosand Safety Code,Sectioon25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: —0
Willtheapplicant or❑future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 1
which emit hazardous air contaminants as definedAirISW DATE
by the Bay Area A
Quality Management District? BOILER-COMP C311POR 100,000 BTM
4 Yes he Q No
haveria teafth&`7i olid Code,ls Sectionrequirements 05,2553aChapter6.95 of BOILER-COMP
the Glifornla lleallh&SofMyCode,Sections 25505,25533 and 25574.1
underda nd that if the building does not currently have a tenant,that it is my NEIN RESIDENTIAL MECH. SQ.pL
wepow1bility to notify the..part of the requirements which must be met
prior to Issuance of a Certificate of occupancy. ss�/s..�,>•
Owner or authonzed agent Date l'{-/a�f�s�'^'P '`"4.
TOTAL: U ISSUED BY:� 1 1 d IA(J ,
OFFICE COPY