20750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
'"- Building Address: n O C O
?ao945o s*Irc G J
1W 00-1 wners ante: one: APPLICA HON
CITY OF CUPERTINO-BUILDING DIVISION ,-r ^9 D
C tractoe IN Lic.No: APPLICATION I PERMIT
• Archlled/Engineer. G s
Lie. . BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLN
QTY ELECTRIC PER IT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ,�. UD ❑ 11 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamllcansefthunder B.provblod Procaden.r9(eomnd my APPLIANCESRESIDE JOB DESCRUTION
ingwlth5edlon 7000)o(Dlvfect. o(lhegusinewand larofesolonsCode,and my
Iic�l(IS,( f1yJ y�gy�dr ,filen. PANELS
Lirene ase ic.N
Date-%!I- a contact.
-r, ARCHITECPS DECLARATION 201-1000 A111 LL.
flO 1 understand my plans ahali be used ss public records OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNSEL CAL
�< OWNER-BUILDER DECLARATION SPECIALCIRC
1hereby afRren that l am exempt from the Contractors Llmew Law for the
p❑pp�( following reason.(Seethm 7037 S,Bwinew and Professions Code:Any city or
county which requires a permit toconsm
tct,alter,improve,demolish,orrepair TEMP.METER OR POLE INST.
q`'0 7 anystructure priorto its iwuance,alsorequUesthe applicant for such permit to
6 ilk a signed statement that he Ls Brewed pursuant to the provisions of the POWER DEVICES
Contractor.LicensaLaw(Chapter 9(mmmencingwith Section 7000)ofDivl- SWIMMING POOL ELECTRIC
cion 3 of the Hueinneond Profmlons Code)orthet he b exemptthercfromand VALUATION
the basis for the alleged exemption. Any violation of Sectbn 70315 by any
< appilcant fora permit subjects the applicant to a civil penalty a notmorethan L%OIJTLETSSWITCITESFIXITJRES • O
live 1,as
owner dollars
Pro NEW RESIDENTIAL ELLCTR SQ.IT. STORIES TYPECONSTRUCTION
�n ❑I,ac owner will
the property,or my employees with wages r thele sole
t roIn&c.mpa 0K Hendee..
an I'Yri�andthe strum:Theure Is Cot intended License Law
5 d for
p sale(Sec.apply
to a new and Pmtmlom Code:The Contactors License Ise
don not apply torn owner ofthrodg his one mporlmproves thereon,ovidedthatand OCC.CROUP RES.UNITS
CC..
who does such work himself orthrough Mbownemployen,provided that such
Improvements are not Intended oroffcrcd forwle.it,however,thebuilding or TOTAL: 3.10
improvementuwldwithinomyearofcompletion,the owner-Wilderwiil have
0Fi;urden of proving that he did not build or improve for purpose of sale.). QTy; PLUMBING PERMIT FEE FLOOD ZONE APN
L_J 6 as owner of the property,am exclusively=trading with licensed
contactors to construct the project(Sm.7046,Business and Profmlons Code: PERMIT ISSUANCE
The Contactors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such plojects with e
c tadoKq Brenwd pursuant to the Contractors Llrense Law. BACK FLOW PROTECT,DEVICE
FEE SUMMARY
LJ I am exemp under Sec B&P C for this reason
DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y_ N_
. 'Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FMTURPS PER TRAP SCHOOLTAX Y_ N
❑I hereby affirorke that 1 have a Im ncate of consenamfttf to pytheurc,ora RECEIPT N
3800,LabCtWorkers'CompensaHanlnsuranreorarertl(led copythemof(Sm. GAS.EA.SYSTEM-I LNCAOUTLErS PARKFEE Y N
Polis Lab C.)
Culmcy N RECGAS EA.SYSTEM-OVER d(EA) HUI LOINGGDDI VISION FEES
&Cnified copy is herebytumecityIAd CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK PEE
❑
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhlssechon need not becompleted lftheperout bforonehundred dollars SEWER-SANITARY-STORM EA.200FT. Date Receipt#
(8100orim.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
that emIn ploy
an persm in any mannerewark w au,to b cone,his subjrmitect
is booed,
I shall not employ any person In any manner w ns to become subject to the WATER SYSTEM/TREATING
Worompenatlon Laws ofCallfomla.Date PAID
O Z Applicantlicant -
Z O NOIICETO e.ubje ttothe, m] making this Certificate of Exemption,you NEW RESIDENTIAL ELMS. SQIT. Date Recei 1#
should become eubjecito the Warken'Camperaatlon provisionsotthe Labor TOTAL:
W Code,you at forthwith compiywlth such provision orthb permit shall be BU NG
W mre
> deeed voked. FEE
0. C CONSTRUCTION LENDING AGENCY SEISMIC FEE Z q
I hereby affirm that there 0s a construction lending agency for the perform- ELECTRIC FEE 3 V sole of the work which this permit 6 bmad(Sm.3097,Civ.C.) TOTAL:
00 I<ndar'sNarm PLUMBING FEE
LL h- I.enders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iudifythatlhavereadthisapplintionandsmtethattheabovelnforrrntlon
S is cod.Iagreelo comply tyand county ordlnanewe and state lawn PERMITISSUANCE FEES PAID:
>. N relat gto bulldlegro tru man d rcbyauthorberepmxa.l.Hveaofthh
F Z city t aterupoothea vemen0on propertyforlmpooloopurpmes. ALTERORADDTOMFGH. Date RCCei t#
—
agree.tow , e Ily an keep harmless the City of Cupertino P
agal 1 bilitio,jud s, Reandeapenwewhlchmaylnanywayaccue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
agai ea In con of the granting of this permit.
AI --
n Q{ R HANDLING UNIT 10,000CFM) CONSTRUCTION TAX
Sign of Applicant/Coo recto Date I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
.W011t a applicant or tutum building occupantstoreor handle hazardous HEATING UNIT(TO 100,00)BTU) Date Rttei [#
eld erlaI as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code�+.-S�ection 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes L_I No
Will the applicant orfutum building occupant use oqulpment or devices VENTILATION FAN(SINGLE RESID) ISSlfplxl(T:T ATE
which emit haza Nous air contaminants as defined by the Bay Ares Air fA1'If fYiS,
• ahty Management Distri07 BOILER-COMP OTU'OR 100,000 BTU)
Yes ❑No
haveread the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) t;lift ` •ty±J
the California Health&Safety Code,Sections 25505,75533 and 2534.I
understand that lthe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which moat be met ^I` ^
prior to lrsuance,of a Certificate of Occupancy. City /O`Cupertino
TOTAL:
Owner or authorized agent Date v
ISSUED BY:�•
OFFICE COPY
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APF ROj/ :
IN ACCORDG E WITH HE RTY OF ° 6 j
�1 / m int '
CUPERTIId�.-.CO ES AND Clf2D�NA ES ,� F Leµ,. !'L�, (� �1
DATE ( u• -
'"V
SIGNED
This set of'plaas and spe rficatyans ,UST . .
r• r ..� r
be kept on th --. OF
yy
lawful to make a .y,chanC s e� It ration.,= I
h{
on Sime wdhqut'W,tion 5c sSAo tram - j
the building DGp+ , PAY:oi r-Or nd. C
The stamping ai hs p.zr, ad �ecih tions ' >,
SHALL NOT be .d to mit or to be io
,.
approval of the l c,3:ijn ' Kpr vision '
1 PRE � � �r
pv. .y .: fr¢.YI•r�[ r7G -A
of any CityOr ance or tate La
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