20313APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pra ect )dentlnutlon
Building Address:
PERMIT NO.
n
U/oo R E AE Ni HI r' 1
O
G V{ 3
netsvie one:
APPLICAIIONSUBMIIIALDAIE
R E E
CITY OF CUPERTINOQBUILDING DIVISION '.
APPLICATION'I PERMIT
6-16
Co trumr'.Name: - Lk. N.
4,1 Ll
BUILDINGFLECTRICALPLUMBINGMECHAMCAL,
CATEGORY
'
CONTROL N
Architect/Englrser. Lk. No:
QTY ELECTRIC PERMIT `FEE
BUILDING PERMIT INFO
Address:'
-Y � IL_
L1�J LJ
PERMPTISSUANCE
LICENSE DCONTRd SDECLARATION
under
Iherecctionrmthat lam Bcen3 ofthe vrprovWonaof ChionsCo e,andm
IngwlthSect1on7000)ofDlvltlon3aftheBuelmeeandl'rafeselonaCode, and my
It... if In full force and effect.
APPISANCFSRESIDENTIAL
B R8f710N
e �,f, /'� i
�a VAN W
PANELS
License Class LIC#
Dale Cotaract xr
2D1-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVFR1010AMP5
SQ. FT. FLOOR AREA
-S/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
' OWNER -BUILDER DECLARATION
Thereby affirm that I exempt -BUILDrom the DECLARATION
License fAwforthe
following means. (Section 7031.5, Business and Professions Code: Any city or
countywhIch mqmi
ubesa pert m
to nstmct, alter, Improve, demolbh,orrepair
SPECIALCIRCU1T/MISC
/�•q�
TEMP. MET17i OR POL81N5T.
anystmc mptl toltslfaame,al mquirestheappllantfamch permitto
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi.
sion3oltheBuslnessand Professions Code)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7011.5 by any
appBant fora permit subjeRetheappllcant to a civil penalty of nor room than
five undred dollars ($50M.
I, as owner of the prep", or my employees with wages as their sole
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLEISSWITCHESFU(Tl1RF5
- VALUATION
O 311 00
NEW RESIDENTIAL ELECTR FT.
SQ
STORES
TYPE CONSTRUCTION
compensation, will do the work and the stm=m isnot intended or offered for
sale (Sec. 7094, Business and Profeadc. Code: The ConlraRofs Lt.. Law
-
does not apply to an owner of property who builds or Improves thereon,and
who doessuch work himself orthrough his own employees, provided that such
OCC. GROUT'
RFS. UNITS
Improvements are not Intended oroffered for ale. If. however, thebullding or
improvementbaa1dwithinoneyearofcompidioo.theowner-bu0derwRl have
TOTAL:
'
t1a�uMen of proving that he did rot build or Improve for purpose ofcakJ.
u L as owner of the Property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Prdns eesloCode:
PLUMBING PERMIT FEE
QTY.-
PERMIT ISSUANCE
FLOODMNE
APN,
The Contractors License Law don nor apply to an owner of property who
builds or Improves thereon, and who contracts for such ptajecre with a
cgR{��dor(s)Umnmdpursuant Mthe Contndoes License Law.
LJ I am exempt under Sec B & P C for this reason
ALTFlt-DRAIN & VEN7-WATER (EA)
FEE SUMMARY '•
BACK FLOW PROTECT. DEVICE
OUTSI OF FEES
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a artlficate, of consent to self4ruamt, or a
Wurenceoracertilhd mpythereo((Bec.
3800, LabC.)
Irl)(TURFra PER TRAP
SCHOOL TAX Y N
RECEIPTN
GAS-
GAS EA. SYSTEM-11NC4 OUTLETS
PARKFEE Y N
policy
RECEDING TTN
Com an
CAS FA.SYSIEM-0VERd(EA)
BUILDING DIVISION FEES
ified copy b heed with the city
ertlfled copy Is filed with the hely inspection dlvlJon.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GRF-ASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM FA. 2(10(•7.
COMPENSATION INSURANCE
Ghlssec ion need not be completed if the permit isforom hundmd dollars
Date Reed tN
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
PAID—
(f100)orless.)
Ianete employ Zany mannehe workr so an to
pessnitisiso the
an person
I shall not employ any person In any manner a u to become subject to the
Workers Compensation laws o(Callfamla. Date
WATER SYSTEM/TREATING
Applicant
NOIICnl
NOTICETO APPLICANT: If, after making this Certificate o(ExempptheLyou
become subjecttothe Workers' Compensationprovisionsdlhe Labor
Date Revel tN
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
Code,
Code, you must forthwith comply with such provisions or this permit shall be
BUILDING FEE
dremed revoked.'
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there he a constrodion lending agency for the perform-
.ante of the work for which this permit b issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I mdRythal l havemadthis application and Gate that theabove Irformation
i.arra.lagreetocamplywlthalldtyandmuntyordlnancesandrtatelaws
TOTAL'
ELECTRIC FEE
PLUMBING FEE
.. -
QTY.' ., MECHANICAL• PERMIT FEE.
MECHANICAL FEE
PERMIT ISSUANCE a
FEES PAID:
relating to building comtrudion, and hereby authorize repmenlstives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnifyas an d keep harmlethe City of Cupertino
against liabilities, judgments,m nand expenses which may In anywayaccrue
against said City an f gr tingdtWspemdt
ALTERORADDTOMECH.
Date Recei 1M
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
-
AIR HANDLING UNIT (OVE910,ODOCFM)
CONSTRUCTION TAX
Signatureof Applicant/Contractor It
EKHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSM IALSDISCLOSURE
HEATING UNIT CID 100,000 BTU)
Date RCCei tit
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Health and Safety Code Section 2S32(a)?
nn Yes No
Rilllheeppllcantor
HEATING UNIT (OVER 100,000 BTU)
.TOTAL:
VENTILATION FAN (SINGLE RFSID)
,N , ,
ISS ATJC''E+DATE
lumbuildingocmpanluseequipmentordevlas
which emit harardous ab contsminamus defined by the Bay Area Air
BOILER -COMP OFF OR 100,IX0 BTU)
Qu a lity, Management District?
No
BOILER -COMP (OVER 100,000 BTU)
My"
Thread the bazar ous materials requirements under Chapter 6.95 of
ca
the California Health & Safety Code, SM ions 25505,25U3 and 25534. I
and erstand that if the building does not currently have a tenant, that it b my
City of Ia,11T1P,rIIfir)
NEW RESIDENTIAL MECH. SQ.FT
respomibility, to notify the occupant of the regWrements which =at be mot
,
prior to Issuance of a Ccr lficate of Occupa ney.
ISSUED BY: n
Owner or authonaed agent - Datee_
TOTAL:
OFFICE COPY