21029 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITN2 1 0 2 9
Bwmmgnaareaa: 6 17 `/ G4�"PSIV�iLL, L�`/
AFPF
caner. ame. one:
N _Ge��s� � rjmo 257-3)2 CITY OF CUPERTINO-BUILDING DIVISION
Cmdmdw'e Name: Lie.N.: APPLICATION I PERMITAlsk
`1
D%x av f .L/ G' BUILDINGELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL Y
A Mtect/Engineen Lk.No: '
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Aaaresa: Ss` �` /,/" PFRFRTISSUANCE Imo[ ❑ ❑ ❑
LIm that ED CONTRACTOR'S DECLARATION L(�
I herebyaffirmmt0)of iv Ocensedunder pessand o(Cha pter9(commenn APPLIANCESRESIDENTTAL JOB DESCRIPTION
Ingwllh SeMon7000)of Dlvlelon3ofthe0uslnessand Pro(esslonsCade,and my
license is in fun end offect. PANELS `�, 1��
License C6ss LiC.Y y 1 � LJ (/I T fJ
Date a• Contractor
ARCHITECT DE LARATION 701-1000AMPS
❑�u p O I understand my plans shag be used es public remrda OVER IOOO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
&d Licensed Professional SIGNS ELECTRICAL
«< OWNER-BUILDER DECLARATION
G a SPECIAL CEtCU T/M SC
z E,. I hereby a son. that I n 7 315,B from the Contractor's License Law city or
oo following reason.(Section 7071.5,Business and ProlmWns Code:My city or
O 2 TEMP.METER OR POLE INST.
P� county which requlreea pemJttommtruct,ilter,lmpmve,demollnh,arrepalr ,
$ an ystmMmpeortottol wancgaborequimatheapplicantfor chperMtto POWER DEVI
ry2 line a signed statement that he is licensed pursuant to the provisions of the
3µy Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- 5WAIMING ELE
OJ slon3ofthe Businmand Pmf,.Wns de).rthathekemmpttherefmmand VALUATION
•7 the basis for the alleged exemption. My violation of Section 70315 by any OUTLETS
<•° appbcant for a permit subjects lheapph..t to a tivil pevlty ofnU more than
F five hundred dollars($500). NEW RES[ LFLTR
rl L as owner of the property,or my employees with wages as their sole SQ' r' STORIES TYPE CONSTRUCTION
compenaabon,will do the work aad the structure Is not intended.,offered for
aJle 7044,Budness ana Professions Code:The ContmRots License Law
$ does not apply to an owner of property who WlldsorlmproveetMreon,and OCC.CROUP RFS.UNITS
E whodoessuchworkhimeelforlh=ghhisownemployees,providedthatwch
Improvements are not Intended oroffered(.male.I{ho sever,thebuilding or TOTAL:
Improvementbsold withinoneyearofcomplMMmtheowner-bu0derwill have
tkiLIturden of proving that he did not build or improve for purpose of sale.). QTY,ATERTDRAIN
PL I PERMI FEE FLOOD ZONE APN
LJ{as owner of the property,am exclualvely Mamsel ing with licensed �AN
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who J,VENT;WATER
Wilda or improves thereon, and who contracts for such plajecis with a FEE SUMMARY
cgD[�actor(s)licensed pe....ttothe Cootr.dm'.Li...Law. BACK FLOW PROTECT. EVICE
LJ I am exempt under Sec. B k P C for Ihis.reawn
IV OUTSIDE FEES
DRAINS-FLOOR ROOF,A SANITARY Y N
Owner Date RECEE'T Y
WORKMAN COMPENSATION DECLARATION FIXll1RES I'ER TRAP SCHOOL TAX Y N
[31 hereby affirm w
that I have a certificate of consent to self-Inre,ora RECEII'P Y
certificateofWorken'Compem hmlmu=a oramnlfkdeopythereo((9ec.
38M Lab C. GAS EA.SYSTEM-I IN O EIS PARK FEE Y_ N_
Palley Y 6 y 3- RECEIPT M
GAS EA.SYSTEM-OVER )
Com anv n'.. �n BUILDING DIVISION FEES
�ertl(ied cop I.filed
the city
CREASE/NDUSIRL WASTEI EPTOR - PLANCHECK FEE
erti(led copy Is flied with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCB SEWER-SANITARY-STORM F.A.7OOFT. Date ReceI ted
Rho action need not be complMed lithe permit V torose hundred dollars
(f10 fy that
le
Icocertrtl( WATER HEATER W/VENT/ELECTR ENERGYFEE Y ' N
atthe performance of larwMth this permit is4wed,
I shall not employ any,person In any maser an as to become abject to the WATER SYSTEM/TRGTINX;
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL I'LMB. SQdR. Dale Recei tN
Z Q NOTICE TO APPLICANT.ILafter ma king this Certificate of&emptlon,you
Hshould become subject to the Workers'Compensation providt of the Labor TOTAL:
CC N Code,you=at forthwith comply with such provisions or this permit shall be BU G t^�
W > deemed revoked. _
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a cortstmctlon leadingagenry,for the perform ELECTRIC FEE
V z Le doffr'a W
the work for which this permit is issued(Set.3097,Civ.C.) TOTAL: PLUMBING FEB
U. I– Lender's Address QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
OW Imrtifythal l have read thitappilcationarul state that theabove information
11. bcorrect.Iagreet.complywithalldty•andcountyorainantesandstatelaws PFRMITISSUANCE FEES PAID:
relating to building construction,and hereby authorice representatives of this
I— Z city to enter upon the above�menlioned property for inspection purposes. ALTER OR ADD TO MECH. Dale ReCei fol
— (We)agree 1 save,Inde an d keep harmless the City of Cupertino P
agalvtliabll • dgmen and expenses which may In any wayaceme AIR HANDLING UNIT 10,ODOCFM) SUBTOTAL:
against sal 1 N conqAecs of the granting of this permit -
AIR HANDLING UNIT(OVER IO,00)CFM) CONSTRUCTION TAX
Slgw App /Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BM Date ReCel fN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
lea t Yaennd Safety Codr�&ctlo
on n7SS37(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 2 a
Rill the applicant oi(ulum building occupant use equipment or devices VWDLAnONFAN(SINCLERESID) ISSUANCE DATE
which omit haurc oua air contandnants as defined by the Bay Area Air
Quality Management QLttrict7 BOILER-COMP QHP OR IOQO(D BTU) PMO(PIS
4
Yo. Tjl No �dW
havcreaa he b eaIth dSIctyCode,S requlremenb under Chapter 6.95.E BOILER-COMP(OVIA 10(1,000 BTU) ���
the GltandtffomIHealth4 building
can 75505,75533 and 75531.1 41990
map. iblftyt i(the allyth lding dart oft ennE memo is tenant that It met NEW RESIDENTIAL MECH. SQ.IT
ruponsibBityt ctlty lfie partOc,tparcy. rensnb which at be met
prior to lss of a ate of Ocavpanry. -• /a tTo4 '
n u o dagent'�F Date
TOTAL: ISSUED BY,
OFFICE COPY