21488 APPLICANT TO FILL INFORMATION WITHIN RED LINES - U1SE•Eik—LLL POINT PEN ONLY
BuildinK Project,1,14nIAlcation -PERMIT NO.
Buildln Address: 1WF
'n 1
_ A V� GIT400
r�p� ��j2Kr�� CITY OF CUPERTIN0.RUILDI GDIVISION (j
Centra er'a'Na I /�I 1 lllYi��f"',,, Lk.Ne: APPLICATION / PERMIT
�b -C�6�7\) - BUILDINGE.ECTRICAI.PLUMBINC-MECHANICAL CATEGORY
Architect/ r. Lie No: F/
,QTY; t ,,tELECTRIC.PERM[T,u', ['FEE+�', t1' .I,:BUILDING PERMIT INFO - f
Add.' - PLRMITISSUANCE 191 1:1
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commane- A P P I IANCFSRESIDENTIAL -'JOB DESCRETION '
Ing with Section 7000)of Division 3 ofthe Business and VmfaesionsC e,and my '
IlrenselslnfuBtormandeffect. .. PANELS
License Clam Lie.p ' T
Date Contractor UPT02DOANU1 y r
ARCHITECTS DECLARATION 301-100(IAMPS -
9z I understand my plareshallbe used as public records. OVER IOOO AMPS SQ.FT.FLOOR AREA S/SQ.ET.
OOb.
t d t,. Llcensd Professional SIGNS ELECTRICAL
L<ul OWNER-BUILDER DECLARATION,
(ii, Fh �
[herebyaNrm thatlam axemptfromthe Conlracterb Lkens hw(or the SPECIALCIRCUIT/MLSC
-
59-@ following reason.(Section 7031.5,Buslnessand Professions CER ode:Anydtyor TpMp.METOR POLE INST. ..
county which requirma permit to construct,alter,Improve,demolish,orrepair
qqF Ci anystmmmpdortoitsL ance,al requimtheappUmntforsuchper tto I'OWFR DLVICFS
Vfile a signed statement that be Is Ikereed pursuant to the provisions of the v
Ow Cm,tractoro License Lew(Chapmt9(rommendngwithSectlon7000)ofDivi-
O
vi Aon3 oftheBukeesand I'micaaldru Cede)orthat heti exempttherefromand SWIMMING POOL ELECTRIC VALUATION 'the basis for the alleged exemption. Any violation of Sim
7MIS by any OUTLE7SES
SWITCHFIMMES
666 applicant fora permltaubjects the applicant to a dvil penaltyof".rothan D
fivehundreddollam(S5W). NEiV RESIDEJIIAL ELECTR .kII.
�n •❑I,as owner of the property,or my employees with wages as their sole S Iff - TYPE CONSTRUCTION
C rompmstloq willdo the wor"nd thestrucure b not intended or offeredfor -41
5 O sale(Sec.7044,Business and Profeaslans Cade:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
S�^ who doessuchwork himself orthrough hisownemployees,provided that such _ ` GROUP RFS.UNITS -
Improvements are net intended or offered for sale.If,however,the building or TOTAL:
Improvement lssoldwithin oneyearofcomplMiorytheowner-Wilderwill have „� FEE
t}eA*rden of proving that he did notbuOdorimproJeforpurpmeofsale.). QTY, PLUMBINGPERMITi •t NE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
-
contractors to construct the project(Sec.7044,Business and Protamines,Cade:
The Contractor's License Law does not apply to an owner of property who ALTERDRAIN&VENT-WATER LEA) f
builds or Improves thereon, and who contracts for such p( d -
oje
a with a - W,
FEE SUMMARY
I
cLCt.fIaaor(s)licensed pursuant to the Contradorn License Law. BACK FLOW PROTECT.DEVICE '
J I am exempt under See B&P C,for this reason
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N
OwnerDate - RECEIPT If
WORKMAN COMPENSATIONDECLARATION
❑I hereby affirm that I have a certificate of consent to self-inwrep0(gUgpS,PER TRAP SCIBOOL TAX Y N
,or RECEIPT M
certificate of Wn
orker4Compereation Insurance ora certified copythersof(See. CAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3500,Lb C3 '.
PMIry RECEIPT M
GAS F.A.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
�Ccrtlfled copy b hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
MCerti(ied copy Is filed with the city Inspection divislon. -
,�S9D4 ��•6
., CERTIPIGTE OF IXCREASETRAP /EMPTION FROM WORKERS' PAID 1t if
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200F1'. Date Remi ted
(rhlssection need not be completed B the permit is forone hundred dollars
($100)ariam.) WATER HEATER W/VENT/ELCCTR ENERGY FEE Y N
I certifythat in the performance of the work forwhich this permit is Issued, WATER
I shall not employ any person in any manner sou to become subject to the WATpg SYSTEM/TREATING
Worker'Compensation Lam of California.Date PAID
O Z Applicant NE'WRESIDENTIALPLMB, SQ.FT. .Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compemat ion provbios of the Labor TOTAL:
N Code,you=at(orthwith comply with'such pmvLaken or this permit shall be
W > deemed revoked. B N , 06
LUCONSTRUCTION LENDING AGENCY SEISMIC FEE a
I herebyatfirmthat them is a comtmdiun lending agcnryfor the perform TOTAL: ELECTRIC FEE
O arse oithe work forwhichthb permit is Issued(Sm.3097,Clv.C.) -
Lender'aName - PLUMBING FEE
V 1— Lenders Addmae - - QTY. ''MECHANICAC,PERMIT LL .1 1' lFEE' 'MECHANICAL FEE -
O O ImnlfythatlluvereadthbappBotionandetatethattheabovelnfomution
abromed.I agree to comply with all cityand countyordinances and elate laws PERMIT ISSUANCE FEESr� SP �,yo
relating to building construction,and hereby author@e representatives ofthls 1 —
I— U) city to enter upon the above-mentioned property for impedion purposes. ALTERORADDTOMECH.
Z Mr)agree to save,indemnify an d keep harmless the City of Cupertino Date ReCeipt4l
.8. at llabEltks,judgments,costs and expenses which may In anywayacxrue 'AIR HANDUNG UNIT(TO 10,000CFM) SUBTOTAL'
ago1l,st said City In consequence of the anting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX'
ofAp t/ ador e• IXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARD US MATERIALS DISCLOSURE -
WRltheapplicantorTutu bulldingeumpant store or handle haeardous - HEATING UNIT(TO 100,000 BTU) Date Recet ted
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
Flealthand Safety Cade dion2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes �A No
Wllltheapplua of futurebuilding occupant use equipment ordevices VENTILATION FAN(SINCI.E RFSID) t ISSUANCE DATE ;C
which emit hazardous air centaminants as defined by the Bay Arca Air R\�
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) Yom'
n❑ Yea jQj No DEC
have read the haz4dom materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) C/1 �
the CGlifomla Ficzlth&Safety Cade,Sedians25505,25533and255M. I- rofl/11
understandthatifthebuildingdoes not cdrrently havcatenant,that it is my NEWRESIDENTIALMECH. • SQ.fT. TJJ�
responsibility to notify the occupant of the requirements which moat be met
prior to Lsuanee of a Canlficate of Occupanry. ���?n�'
Owner or agent Date
authorireda 1 r
. B •TOTAL: ISSUED BY: -
OFFICE COPY