20757APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL00U4T-PEN1WLY
Building Project idemificmianl \ `V11VL
Building Address: `
7 6 S—S line Gv-iZ /v4/
PERMIT NO.
` 20757
ner• ams: rte
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as
CITY OF CUPERTINO-BUILDING DIVISIONo
APPLICATION I PERMIT
BUILDINGELMTRICA[PLUMBING-MECI IANICAL
p
— 3
ntra r.N LIc.No:
S O �S o G-
CATEGORY
CONTROL N
Architect/Engi r. L No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Q
Address: � S— a
I PERMIT ISSUANCE ��
❑ � ❑ ❑
LICENSED CONTRACT R'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc.
ingwhhSection7000)of Divlsim3ofthe Buslonasand ProfessioneCode,and my
Ilcenee is In dLidefed
` p
APPf.IANCESRESIDENTIAL
JOB DESCRR'IT$)N
PANELS
Date Contractor
201-1000AM
ARCHITECPS DECLARATION
OVFR 1000
SQ. FT. FLOOR AREA
$/SQ. FT.
I understand my plane shall he used as public records.
Licensed Profesiowl
pp
SIGNS ELECTlU `\
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt fromthe Contractors License law for thefollowing
reason. (Section 7m15, Badness and Professions Code: My dry or county which mqulrn a permit to con.trod, alter, Improve, demolish, orrepalh
permirto file a signed statement that he is licensed pursuant to the provisions of the
NSPLCIRCPI
Contractors License Law(Chapter 9(commencing with Section 7000) of Divi- slop 3 of the Butlness and Prfessione Code) or that he b exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 70115 by any
Applicant fora permit subjects the applicant to a civil penalty of not more than
TCFJESSFIXTURES
NEW RESIDENTIAL ELECTR SQ.FT.
s
five hundred dollen ($500).
❑ 1, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
` 4 9 0
compensation, will do the work and thestructure is nm intended or offeredforI
sale (Sec. 7044, Business and Professbne Code: The Contractors ntraors License Law
don not apply to an ownerofproperty, who Wilde orimpown thereon, and
doesuchwork himself orthrough his own empioyen, provided that such
OCC.GROUI'
RES. UNITS
Improvements are not intended oroffered foreale, If, however, thebullding or
Impmvementswld withinomrarofcompidlogthe ownerbuilderwill have
TOTAL:
the burden of proving that he did not build or Improve for purpose ofsale.).
L) L as owner of the prop", contracting with licensed
p perry, am.7044, Business
to construct the project no and Code:
QTY. PLUMBING PERMIT FEE.
PERMIT ISSUANCE
FLOOD TONE
APN
TheconContractor's
acts to a
The Contnctp License Law does not apply to f owner of property who
nor apply of property
Wilds or Improves thereon, and who contracts !rn such ptojects with
the Contractors License Law.
ogRf[+dmexe medput ndernotant Sec.
LJ 1 am exempt under Sec. B 4 P C for ehb reawn
ALTER -DRAIN k VENT - WATER IEA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FEES
DRAINS FLOOR, ROOF, AREA, GOND.
pp(03Jgps PER TRAP
SANITARY Y N�
RECRUITN
Owner Date -
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to selfdnaure, or •
000 ateo/Worken'Compewtlonlneurance oracartRled copy thereof (Sec.
ab CEJ
SCHOOLTAX Y_ N
RFLF9 IN
S FA
GA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
ky N
RECh'E'T N
GAS EA. SYSTEM -OVER 4 (RA)
sny
BUILDING DIV] SIONI9(ES
Certified copy V hereby tarnished.
enUied copy V tiled with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhiswctlon need net W completed if the permit V (Drone hundred dollars
($100)orles.)WATQt
I acridly that In the performanceaf the work for which this pecout is blued,
I shall not employ any person In any manner w as to become subjed to the
Workers' Compensation Laws of California. Date
PAID
Date Recei tin
D
SEWER -SANITARY -STORM EA. 200PT,
WATER HEATER W/VENT/F7.LOTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TRGTINC
Applicant
NOlicant APPLICANT-. If, cher making thio Certificate of Exemption, you
should become subject to the Workers'Compermdion provbioru of the Labor
Code, you moat forthwith comply with such provision or this permit shall be
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB. SQjrr.
TOTAL:
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyafflrm that there is aconstroctinn lending agency for the perform-
ance of me work for which thio permit b issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
landae Name
Lenders Addren
Icenifythati"ve madthisapplicationand matethattheabme infor=tlon
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Is correct. I agreelo complywith all cityand county ordinances and state laws
PERMIT ISSUANCE
relating tobullding construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Iodemnily an d keep harmiess the City of Cupertino
ALTER OR ADDTOMECH.
Date Recei t#
P
SUBTOTAL'
against liabilities, Pdgmens,costsend expense. which may In anywayactroe
again id In consequence of the o..�r�.o of thio Der
—� /�
AIR HANDLING UNIT (TO 10,OWCFM)
AIR HANDLING UNIT (OVER I QODOCFM)
CONSTRUCTION TAX
Slgoa rc nnt/Conhractor `
E%HAUSTHOOD(W/D(X-D
CONSTRUCTION TAX PAID:
?"a
HAZARDOUS MATERIALS DISC SUR
HEATING UNIT (TO 100,000 BTU)
--
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date Recei I#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Health and Safety Code Section 25532(a)7
❑ Y. NN.
Wllltheapplicant orfuture building occupant seequipment ordevirce
VENTILATION FAN (SINGLE RESID)
Iq)r_avawE.q DATE
QW
which emit hazardous alr contamWant. as deflned by the flay Arca AU
BOR.F.R.COMP(3FE'OR100,0(DBT(JI ,
Quality Management District?
No
Ihave read the lt.a'smaterials requirements underChapter6.95of
the California Health A Safety Code, Sections 25505,25533 and 25534. 1
90MER-COMP(OVER 100,000BTU)
NEW RESIDENTIAL MECH. SQFL
understand that if the building does not currently have a tenant, that it u my
responsibility to notify the occupant of the requlrema:nts which most be met
yea t .y,
CIaJ OI CUBesN O
n
prior to issuance of a Certificate of Occupancy.
ISSUEDB ,
Owner or authorized agentTOTAL:
e
OFFICE COPY