20182APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Bu lading Add ress:
10100 Toak.;4, Av _
a.
PERMIT NO.
n O
, G 1 82
wee s ante: one:
(576
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-FlECTRICA4PLUMBING- MECHANICAL]8f
eent�rajnn'eName: /� ue.No:
�l E=�M I�.a POO L. 2 Pse
CATEGORY
CONTR
�a I
ArthitpectL/Engineer. �j.k. No'
4 IL1Rt (, �..M*I ( �OM �S�
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
il[j
? �
PEM WUANCE am
LICF.NSEDCONTRACfOR'S DECLARATION
T hereby affirm Rut l am licensed under provisions of Chaptcr9(mmmene
Ingwlth Section 7000)o(I%vlslon3 ofthe Businemand Pro(nelonsC-ode, and my
license is in(uB orceand effect.
License Class Ltea
APPI1*VWWDRNDAL
JOB DFSCRQ'TION
Date� a Cnntnaor — ob LS
-1
ARCHITECTS DECLARATION
I understand my plans shall be used ax public records'
OV0tWAMNJU
SQ. Fr. FLOOR AREA
$/SQ. FT.
SICVISELF' L
Licensed Professional
Lk�ECN
OWNER -BUILDER DECLARATION
1 herebya(Rrm that I am exempt from the Contranors License Law Pathe
-
PILE S.
51
following reason. (Section 7B3lS, Business and Professbns Gds: ydty or
mantywhkh rtqulmaa FermittoroeseroQalter, lm prove, demolish, repair
anystmctom prontoits Issuance,alsorequlresthi a'PH. (crouch iso
file a signed statement that he Is licensed pursuant to the provialov f the
SIN � POOL C
EX7l1RF5
Geta fthe utdoLicenLdProfesion (rommencung wkh Section 7000 v
,on3o(the Budnaaand Pro(emlonu Code)orthat It b ro d
the basis for the alleged exemption. Any violation of Section 7
applicant fora permit subject/ the applicant to a civil penalty of not
/tom VA
five hundred dollars ($500).
n I, as owner of the property, or my employee with wages as t Ir sok
NEW R AI ELEC7R SQ,91ra
'E CONSTRUCTION
IVU
compensatuon, wi ldothe work and thestrocture is not Intended or offered for,S
sale (Sec. 7044, Business and Pm(eaeioro Code: The Contracme. License Law
does not apply to an owner of property who builds or Improv. thereon, and
whodoessuchworkhtm iforthroughhisownemployees,provkiedthatwch
Improvements are not intended oroffered formic. If, however,thebuilding or
Improvement hoold within oneyearo(completion, the owner-builderwill have
TOTAL: Za
RES. UNITS
I
tll9�urden of proving that he did not build or Improve for purpose at sale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
DZONE
APN I
PERMIT ISSUANCE
x ('�
The Commodes License Law does not apply to an owner of property who
builds or Imprwea thereon, and who contracts for such pwjects with a
cgnactor(a) licensed pursuant to the Contractor's License Law.
I am exempt under Sec. B 4 P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT, DEVICE ,�OUT.,
OF FEES
DRAINS FLOOR ROOP, AREA, COND.
SANITARY Y N
RFLEPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby atfimn that 1 have a certificate of consent to self -Insure, ora
3800, Lab GmAifluteofWorkers'Compeesadon Wunnce ora certlfkd copy thereof(Sec.
Policy
FIX'IURFS PER TRAP
SCHOOL TA% Y_ N
RFL®PT N
GAS EA. SYSTEM -1 INCA OUTLETS 66
PARK FEE Y N
RECEIPT M
Y
Gm ant/ 1 1 QL (] r
cc
copy is hereby furnished.
❑ CcnaBed copy In filed'Mth the city inspection division.
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OFE(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ghlsseniao need not be completed If the permit la forme hundred dollars
($100)orless.)
lenifythat inthe perfomunmotthework forwhichthis permit le Issued,
I shall not employ any person In any manner w as to become subject to the
Works Compensation Laws of CaBfomua. Date
--77
PAID
Date RCCCI 1#
O(a
SEWER -SANITARY -STORM EA. 2110Ff
WATER HEATER w/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/1REAING
Applicant
NOTICE TO APPLICANT: H, after nuking thisCenifiate of Exemption, you
should became subject to the Workers'Compensation provisions, of the Labor
NEWRFSIDENTIALPIMB. SQFT.
Dale Recel 1#
TOTAL:
BUILDIN G FEE
Code, you muse forthwith comply with such provisions orthis permit shall be
d.med mocked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyaf0 onthat there is a romtruction lending agency for the performTOTAL:
ce at the work for which this permit Is issued (Sec. 3097, Civ. C.)
Tender. Na ox
Lenaera Addree
I certify that I have read this appBation and Yate that the above in(ormatlon
laror ost.Iagree to comply with all city and county ordinances and Yate laws
ELECTRIC FEE
Qi
PLUMBING FEE
(01co
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE .�
FEES PAID:
,
relining to building construction, and hereby authonae representmives of this
city to enter upon the abovrmentimud property for bupection purposes.
(We) agree to save, Ind courtly an d keep harmless the City of Cu pen Ino
against liabilities, judgmenb,.Ysand expenses which may In any way accrue
ALTER OR ADD TO MECH.
Date Revel [#
AIH HANDLING UNIT CT010,0W CFM)
SUBTOTAL:
against City In con lard of the granting of this Formal.
6 ?,i
AIR HANDLING UNIT I0,0D0 CFM)
CONSTRUCTION TAX
wtu o AppRam/Contractor Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,0D0 BTU)
Date Receipt#
Wills applicant orfuturc building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ileahhand Safety Coder_ Section25532(a)7
F1 Y. , I—I No
Will the appliant.,Ptumbullding occupant use equipment ordeviros
HEATING UMT(OVERiW00 ,0BTU)l
TOTAL:
s OT
VENTILATION FAN (SINGLE RESIW
ISSUANCE DATE
which emit havrdous aur contaminants as de0ned by the Bay Area Air
Quality Management Disttdct7 -
❑ Y. N9
uenread the havrdous matenab requiremenb under Chapter 6.95 of
have
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 B TU)
the California Health &Safety Code, Sections 25505,25533 and 25534. T
understand that if the build Ing docs nut currently have a tenant, that it is my
NEW RESIDENTIAL MECFi. SQ.Fr.
respowibButy to notify the occupant of the requirements which at be met
prier to issuance of a Certificate of Occupancy.
-4-at/-qj)
s�4��-�l��C1♦�1����(,�^��
erorauthonaed agent Date
TOTAL: t`] pt^
OFFICE COPY