20305APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — POINT PEN ONLY
Building Pro ea Identification
Building Address:
PLRMJTNO.
10/ 00 'MXAE f} -UE U��T c5 i f � �
20305
nets one:
E
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
'510cl 96
con:ndar. Name: LIC, No:
BUILDING-ELM'DUCAGP6IJMBING-MECHANICAL
CATEGORY CONTROL N
Arthlted/Engineer. Lk No:
QTY ..ELECTRIC PERMIT FEE
PERMIT INFO��,,//
Address
,,--B/BUILDING
.f�1i F �✓1
l� LJ LJ
PER,WTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
[hereby a(firtntlutlam lbneed under prwblone ofChapter9 (commanc,
under pr
ingwlth Sed1an7000)a(Dlvision3ofthe Buslnnsand ProfeWonsCode,and my
license Is In full forte and effect.
APPLIANCESRES[DENI7AL�F�RB�7QN
c,V"c) �-
PANELS
License Clam ic.0
Dare Conmc10
IM TO 2DOAMPS
701 -IOW AMPS
ARCHITECTS DECLARATION
I understand my plam.lull be used as public racords.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
$M. FT.
SIGNS ELECTRICAL
Licensed Profemlmul -
SPECIALCIRCUT/MISC
OWNER -BUILDER DECLARATION
Ihereby afflrmthat I am exempt fromthe Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or
countywhich requires a permittotomhuct, alter,lmpmve, de=Ush,or repair
DLJ
TEMPMETER OR POLE INSr.
anystmmmprlorwibbarame,WorequimatheappUmnttorsuchpermltto
file a signed statement that he is licensed pursuant to the provblom of the
Commdore License Law (Chapter 9(commencing with Section 7000) of Divi-
Non3ofthe Bu.leeeand Prefeselom Code)arthat he is exempt lheref Omand
the basis for the alleged exemption. Any violation of Section 7001.5 by any
applicant fora permit subjects the applbantto a civil penalty of not nnre than
[OWER DEVICES
.
SWIMMING TOOL ELECTRIC
OUTLETS-SWITCHFSHJ(TURE5
VALUATION
I f e
II:JJ II s f
NEW RESIDENTIAL ELECTR SQFT.
five undred dollars (ISM.
61, as owner of the property, or my employees with wages as their.ole
mmpumatiun,w0ldothe wmlk.ndthestmcture isnot lntendedar offered for
STORIES
7Y1'E CON57RUC7TON
, /�
sale (Sec. 70K Business and Professions Code: The Contractors License Law
v
docs not apply to an owner of property who build. or Improve, thereon, and
whodonsuchworkhimseBorthrough Msownemployees, provided that such
Improvements are not bended oroffered forsale. If, however, thebuilding or
TOTAL:
OCC. GROUT'
RES. UNITS
Improvement baold within oneyearofcomplelbn, the owner-bullderwlll have
the Wrdenof proving that he did not build or improve for purpose of sale.).
0 L all owner of the property, am exclusively contracting with licensed
contractors to construct the pm*d(Sec. 70K Buslneesand Pmfenlom Code:
•QTY. PLUMBING PERMIT FEE
�_�
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law don me apply to an owner of property who
builds or Improve thereon, and who contracts for such pwocis with a
cgl4actor(s) Bndnsed pursuant to the Contractor's License Law.
L) I am exempt under Sec B & P C for this mason
ALTER -DRAIN VENT WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_ ,
RECEIPT N
Owner Data
WOR IRMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-lnsure, or
maiflateofWorkere Compematlonemuranceor..nifiedmpytheteof(5ee.
3800, Lab C.)
Paltry
FIXN1tES ITR TRAIL
SCHOOL TAX Y N
RECEPI' N
GAS EA. SYSTEM -1 INCAOUTLETS
PARK FEE Y N
RECEIPT_
N
Comm an
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
LJ [(led ropy le hereby famished.
ertlled ropy b (fled w1R the city lrupecilon division.
GREASE/WDUSIRI. WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAPPAID
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
SEWER -SANITARY STORM EA iWPr. QQ
COMPENSATION INSURANCE
(TFlssedbn need not be complMed if the pemdt is forom hundmd dollen
( Date Recei t#
WATER HEAT•FAW/VENT/ELECTII.Ir'}t
ENERGYFEE Y_ N_
($IW)orl..)
I evnifythat In the performance ofthework forwhich this permit is issued,
WATER SYSLT.IM /.[RFA.DNG If CimeII,y I
1 shall not employ any person in any manner so as to become subject to the
Workers' Compensation laws of California. Date
MAID
.
Applicant
NOTICE TO APPLICANT: I, after making thisCerUflate of Exemption, you
should become.ubjed W the Workers' Competuatlon provitlom of the Labour
Date Recet t#
NEW RF MDWnAL PLMB. SQFT.
TOTAL:
BUILDING FEE
l 001
Codayou at forthwith comply with such pmvisioru mous permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
a
I hereby aorkfoluttherebammimctlon lending W7,Civ. the perform
for which this permit b lowed (5...3097, Civ. C3
Land eof r's Name
Iaadae.Add
Lenders Addreo
I cenifythm I luvereadthb applimtbn and rtatethattheabove Infomutlon
bcorrect. l agree to comply with all city and county ordlnanceeand Mate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY.'—'e ;MECHANICAL.PERMIT; a FEE :
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to bullding comtrudion, and hereby authorize representatives of this
city to enter upon the above-mentioned property for impaction purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertbo
agaWtllabilltles,(odgmenb, dsand es ensee whlchmaylnanywayaeerue
ALTER OR ADDTO MECH.
Date Receipt#
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
agalmt/�idfJWI he amY this pr�mi/t/�
AIRHANDUNG UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
_ "O
Signature of AppBAZARntrador . a�
-
EXHAUST HOOD(W/DIX:'D
CONSTRUCTION TAX PAID:
HAZARDOUS MATER SUISCLOSURE
HEATING UMT(TO 100,000 BTU)
Date ReceI tN
Will the as .fined by or store ode,Crlundle hazardous
future ftinoM Municipal
material as defined by the Cupertino Municipal Code, Chapter9.12, and the
Health and Safety Cade�s —S�ection 25532(x)7
M Yes I�JNo
IiEATWG UNIT (OVER 1 W,000 eTU
TOTAL:
6
VENTILATION FAN (SINGLE RESID)
ISSINCE DfATE
PAID'
J:J
Willthe appliant or(ulum building occupant use equipment or devices
which emR havrdous air contaminant. n defined by the Bay Area Air
Quality Management Dbind7
Yea No
have read the hares owmalerials requirements under Chapter 6.95 of
the Ca Vomb Health & Safety Code, Sections 25505, 75533 and 25534. 1
understand that if the building does not currently have. tenant, that it is my
BOILER -COMP OHPOR 100,000 BTU)
BOILER.COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
respamlbOlty to notify the occupant of the requirement% which moat be met
prior to Issuance of a Certificate of Occupa ney.
/� �s
�Iftf Af r1irpI'I.10(3
BY� Q : J �100
Owner or authorized agent Data
TOTAL:ISSUED
OFFICE COPY