23485 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification PERMIT NO.
B°°°ing Addrc.,: 2 3 4 8 5
. tee.
nen sere. one; APPIJCAfION
SUBMITTAL
,p CITY OF CUPERTINO-BUIL GDIVISION
conmttoa�Nr�o �/+4 � yly� APPLICA' I ERMI rlL
/'c�/Vsay� S9 BUILDINGELFLTRICAL BINGM q C RY CONTROL N '
Archite t/Engineer. LIB No:
S G QTY EL PERMI BUILDING PERMIT INFO
Address:/��'O - S PERMI I E �� ❑
LICENSED CONTRACTOR'S DECLARATION LOrr
I herebya(firm that l amlicensed underprmislons o(Chapter9(mmmeno CFS 9 OB DESCRIPTION
Ing with Sectlon7000)of Div act,3ollhe Busineuand Prolesslons Code,and my
license la In B form and diet. '
' License Class Lic-N I '
Date Contrador Tnw
ARCHITECTS DECLARATION IDI-IMO AM
q�u X Iunders�myplane is be used as public mroNs, OVER10110 PS SQ.FT.FLOOR AREA S/SQ.FT.
i Fe Limned Profs'—mlo� SIGNS ELEC CAL ("� }�T
< OWNER-BUILDER DECLARATION SPEC CIRCUIT/MLSC CJ
Z I.., � Ihereby affirm thatIase exempt from the Contractor's License Law for the '
QQ following reason.(Section 70315,Business and Pmfesshms Code:Any city or
Fs'ey countywhich requireaa perenittomrotrut,alter,Improve,demolish,orrepair P.MEI'ER OR POLE INST.
`a 7 anystmd mprlortoihi ame,abomquireatheappUmntforauchperMtto
file a signed statement that he b licensed Pursuant to the pro"goru of the I'OVVF-R O C11-41,
3w Contratore License Law(Chapter 9(mmmencing with Section 7000)ofDivi.
ElOS slon3 of the Business and Professions Code)or that he b exempt therefrom and VALUATION �+
y.' the basis for the alleged exemption. Any violation of Section 70312 by an O ��
I9<5
Applicant a permit subject the applicant to a civil penalty of no more than �— J
ppff five hundred dollars(5500). NEW RESID L ELEC 1
I,as owner of the property, SQA• STORIES TYPE CONSTRUCTION
cemZ ❑ p early,or my employees with wages r there sole
540 sale 71314,Business
and rkand thestrots:The isnot Contractor orofferedLw A-r[
K O ole(Sec.apply
to alnan ow and f grope ly Code:The Contractors thereon Law
$$ donnet apply torkhi ]forth ghhisobuilds emplyees,p eldedreary and OCC.GRO(IP RIS.UNITS
whmdoeasucharenot msededoroughh0owne.If,ho eprovidedthatmch ildinger
Improvementsarcnotintendedvaro(co locule.ILhmwevepthderwilln ve /"'
Improvement leeold wlthlnoneyearofcompldloM theownerbuilderwill have
t1,,�urden of proving that he dkirm build or Improve for purpose o/ole.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with llmnaed FLOODZONE APN
contraction to construct the prret(Sec.7044,Business and Professions Code: PERMITISSUANCE
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
builds or Improves thereon,and who serratet
for such plujea with a
cgBtTado,(.)licensed pursuant to the Contndor'a License Law. FEE SUMMARY
LJ I am exempt under Sec. - B h P C for this reason BACKFww PROTECT.DEVICE
OUTSI UP FEES
Owner Data DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y RECEIPT=N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a cconsentFDCrURES PER TRAP SCHOOL TAX Y N
lfio!consent to sell-Insure,a a RECEIPT N
isi'La
mte of Workera'Comperwtionlrourance ora aml(led copy thereof(Sec.
3800,GbC.) GAS EA.SYSTEM-1 INCAOUTLHTS PARK ITiE Y_ N_
Y Com
1'oliryN ON Fr salt DING N
S an GAEA.SY5I'PMAAI BUILDING VGR6(E0I1VISICIN 14iliS
�2ey11lled ropyb hereby(umished. GREASEANDUSIAL WASTE INTERCEPTOR PLANCHECKFEE
tilled copy la(fled with the dry Inspection division.
CERTIFICATE OF IXEM PFION MOM WOR KERS' GREASE TRAP P
If f;3
COMPENSATION INSURANCE SLIVER-SAMTARY STORM EA 100IT. a Recei
(Thio setlon need nd be completed If the permit b forone hundred dollars
($100)orless3 WATER HEATER W/VENT/ELECTR IE -RGYFEE Y
[atony thatInthe performance ofthework wast bthispermit Is Issued,the 1
I shag not employ any person In any manner at n to become subject to the WATER SYSTEM/TREATING L `
Workers'Campensatlon laws o(Olifomla, Date pAlp
Z Z Applicant Date eCCI t#
Z O NOTICE TO APPLICANT.If,ager making this Certificate of Exemption,you NEW REMDENMAL PLMB. SOFT.
should become subject to the WorkeiY Compecestion provisions of the Labor TOT
AL
P:
N Cade, ou meet forthwith comply with such provisions or this permit shall he -
deemed revoked. BUIL INC ECE S
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
' � Z ance ofthe work forwhichthis permit b issued(Sec.3097,CIv.C.) TOTAL. ELECTRIC EEE
02 Landers Name
1L Landers Address - CITY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedilythat l have reedthis application and statethal theaboveinformation
Is correct.l agree to comply with all etyand munneordinenm and tare laws PERMIT ISSUANCE FEES PAID:
} IL relating to building cemtrudion,and hereby authoixe represenbti, o(thls
(. W city to enter upon the above-mentioned proporty for inspection purposes. ALTER OR ADD TO MUCH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,Wdgments,cons and expenses which may In any way amus AIR HANDLING UNIT HO 10,000 CFM) SUBTOTAL:
againstsaid ty In sen aofthe granting of this permit.
9th
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
SfMSwm of Applicant/Contractor Daze EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica nt or future building smut pant store or hand le hazardous HEATING UNIT(TO 100,"BTU) Date ReCei #
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I lealth and Safely Code Section 255..W? HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yea No
Willthe applicant
or turebullding occupant use equipment or devices VENTILATION PAN(SINGLE MID) ISSUANCE DATE
which emit hautdouialr contaminants as defined by the gay Arca Air IA �y
Qaality Management District? BOILER-COMP U HP OR 100,000 BTU) 6� a'4ID
4 Yes 4 No
havercad the bazar ous materfab requirementsunder Chap(er6.95of BOILfiR-C'OMP(OVEt 100,000 BTU) ����� Q
the Glifomla Health k Safety Code,Sections 25505,25533 and 25534.1 jasaa�
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI'nepa�rYGJ
prior toibilityte of ify aCeheic to ant ofO ft he requirements which must be and .` �— .CII r Ur CUr
prior to Lssuanre o(a Certificate ofOmpanry. yIIIV(J
Owner or authorised agent Daze ISSUED BY �•T}S'�
OFFICE COPY �Ki�