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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentifiationPERMITNO.
Building Address:
10 2tl T o
23974
nese ann: ane:
Vt6+'jL0',a
CITY OF CUPERTINO-BUILDI (VISION
APPLICATION I P MIT
A
�1
b
Contractors Name: Lie. No:
BUILDING-ELECTRICA PL INGMECHAMC LCATEGORY
ArchitM/Engineer. Lie Nm:
QTY ELE
RI RM1T
FEE
BUILDING PERMIT INFO
Address
PERMIT ISSUA
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
(her by Sectio lrmthat lamlkenaefthunder Buinmanprovisions olChapter9de,and c
limeseIngwith i.fullfameafdeffiemn3 o(the Budnemand ProfeasloneCode,and my
license le In (u0 farce end effect.
DENTIAL
rrr DP T
1V7`� /
P
CClarkLie tr
_Lt.
LimDate
D
Date
201
ARCHITECTS DECLARATION
I understand my platy shall be used as public records..
OVERI000
SQ Pr H.00�EA S/�F�
Licensed I1olemimul
GNS ELRW
OWNER -BUILDER DECLARATION
I hereby afOrm that I am exempt from the Contractor's License Law for the
SP[CIALC T/MIST
TEMP, MrTIRiDRPOLEI
following reason.(Section 7031.5, Business and Professions Code: My city or
county which requires a permit to costmct, site, improve, demolish, or repair
any stmdure prior to its issuance, also mqu ince the applicant for such permit to
Ole a signed statement that he is licensed pursuant to the provisions of the
Contactor'. License Law (Chapter 9 (commencing with Section 7000) of Divi-
gon 3ofthe Buslnsm and Pran slam Code) or that he ismampt therefromaed
the bash for the alleged exemption. Any violation of Section 7031,5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
(Iv undred dollars ($50�.
I as owner of the property, or my employes with wages as their sole
pp(ygg DEVICES
/
SWIMMING POO 'ELECT RIC
OUTLETSSW{TCETESFIXil/RE5
VALUATION
Y a/�
L �r
NEWR P.MTAL ELECTR SQ.FT'
STOW E5 I TYPECONSIRUCTION
c pensat(un,willdothe work, and thestmdure is not intended or offered for
sale (Sec.706a, Business and Profemiom Code: TheContranofs License raw
'
r
TMAL, n
QTY. PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN A VENT- WATER (EA)Pff
does not apply to an owner m(pruperty who builds or lmprovs thereon and
work himselforthmwgh Ms own employees, provided that such
Is
improvement ere not intended orofferM for ale. IL howeve, lhebullding or
Improvement Is sold within one yearofcomplertlon, the owner-builderwill have
thX,lifunien of proving that he did not build or improve for purpose of sale.).
"L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See 70K Business and Prefemios Code:
T'he Contnnor's License Law does not apply to an owner of property who
or Improves thereon, and who contracts for such p(ojmu with a
cgp((actor(s)It... d pursuant to the Contrador's Lim.. I.
�I I am exempt and r Sec. B k P C for this reams
P, RIS UNITS
....
APN
JWilda
BACK FLOW PROTECT.
FEE SU MMARY
ru US] OF FE ES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
N
Owner Date
V&RIUvRECEIPT
10
1 COMPENSATION of
Of hereby affirm that I have a certificate of consent to seB-Inwre,
FIXTURES PER TRAP
SCHOOL TAX Y N
or a
srdWorken'CompewaBonlauranceora certifkd copythereof l5ec.
3800,,L.ab C.)
RECEIPT N
GAS EASYSTEMI WC.NOUTLETS
PARK FEE Y N
PolbC.
'I'N
ComIt
an Y
GAS EA. SYSTEM-OVER4(EA)
DING
BUILDING DI VISI NFF. ES
Certified copyb herebythM
Certified copy b filed with thee city
ity Imapectlon division.
GREASE/INDUSML WASTE INTERCEPTOR
PLA CHECK FEE
I 4L
CERTIFICATE OF LT(ETIPTION FROM WORKERS'
COMPENSATION INSURANCE
need not be completed tithe permit Is forms, hundred dollars
(T)or In.)
(5100)oify that
I certify that In the perfomance of the work for which this permit Is bored,
I shall not employ any person In any manner so u to become subject to the
Workers Cmepensatlmn hwsmf Calllomla. Date
NOTICE
NOTICE TO MPLICANT:IL after making this Certlflate of Exemption, you
should become subject to the Workers' Compemation provisions of the Labor
Code, You swat forthwith comply with such provisions mrthb permit shall be
dMIMd revoked.
`.
P
t RCCC , �•,
ENER YFEE
PAIDApplicalV�—
a ,Cel
GREASETRAP
SEWER -SANITARY -STORM EA 200FT
WATER HEATER W/VENT/ELECTR
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFI'.
TOTAL:
ILD
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there b a construction lending agency for the perform,
saes of the work for which this permit is Issued (Sec. 3097, Clv. C.)
Lender'. Name
Lteder'.Addreae
I maifythatl have read this application and datethatthe above information
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Iscorred.Iagree to comply with all city and county ordinances and gate laws
PIRMITISSUANCE
mialing to building ronsWction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for inspection purposes.
(W,) ager to save, Indemnity an d keep harmless the City of Cupertino
against liabilities, jdgreents, costs and expenses which may In anywayacctue
against City In conequenre of th sting of this pe IL
i n ,QOM
ALTER OR ADD TO MECH,
Date RCCCI til
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL: ori.
AIR HANDLING UNIT (OVER IO,WOCFM)
CONSTRUCTION TAX
Sig of paZARDtador / sale r�
E%I FAUST I10oD (w/Dl)CT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Wlilthe,ppliant orfuture building occupant store or handle hazardous
material as deft red by the Cupertino Municipal Code, Chapter 9.1 Z and the
Date ReceI tN
HEATING UNIT (OVER I OO," BTU)
TOTAL:
Health and Safety Code Section 25532(1)7
I Ys No
devices
111th, hap icand mlos toremildingnants as
nt usedby the Day Area
whichemit hazardous air contaminant as defined by the Day Ara Alr
Qu a Illy Management District?
Ya❑Nohave
VENTILATIONLE RESID)
ISSUANCE DATE
A y
A 1 D
BOILER0,0W BTU)
RORER000 BTU)
read the hazardousmatedals requirements under Chapter 6.95 of
underslifornia tand that litthe building dade, Sections a nott currentllyhave5a tenant 3 and rihatltlI. my
responsibility to notify the occupant of the requirements which must be mot
prior to lauance of a Certificate ofOmpancy.
m/Jj(](��
��� {6 st IJv7G
'CIIy ur'Lurr2 i
NEW RE. SQ.Fr
ISSUED BY:yI�/ �
Owner or autwlzed agent pate
TOTAL:
OFFICE COPY