19745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification 7 PERMITNO.
Building Address: q
3N.teGf,E 1e,0 VUf/G /-AAID I
nersName: phone: pEON SUBMI I IAL
a CITY OF CUPERTINO-BUILDING DIVISION
• Lic.N.: APPLICATION /PERMITc�?r NMS .A-1vS
Y a G 4�4BUILDING-ELECTMCALPLUMBINC-MECHAMCAL CATEGORY CONTROL Y
Arenitet/En 7VAAA/V Cafe;' ,GA- uc No. BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
naarea:l5"'0 //AuT/•/p,Ci'k �Gv� iiQ .
PERMIT ISSUANCE ❑ ® ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirmthetf tv Ecen3 ofthe erpressand Pro nsdonsr odeand(commenc.
my APPLIANCESRF,SIDENTIAL JOB DPSCRB']30N
ingwfthouse .1.full9000)and effect
ofthe Bu�s/lnessandProfeelonaCode,and my
G cener Class II folyx andL�Y V 7/ a 6'/ PANELS 11
L Q c
Date Z� i 01 �dContraRor —UP TO MO AMES
ARCHITECT'S DECLARATION 2014000AMPS
�2 ]understand my plans shall be use as publicremrds. OVER lODO AM['S SQ.FT.FLOOR AREA $/SQ.FT.
GO
a Z V License Professional SIGNS ELECTRICAL -
<re OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
i.., 7 Thereby a(Orm tNal]ace exempt fromthe Contratorb License law for the
ZO F'ggq� following reason.($ection 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
county which requires a permit to mrmtrud,alter,beeprove,demolish,or repair
any structure prior to its Issuance,also requires the applicant for such permit to
POWER DEVICES
e file a signed statement that he is lkepursuantm
nsed to the provlsloof the
Contractor's License Law(Cha er9(commoncin with Section 7000)of Divi- / VALUATION
elon3ofthe Business and Prtessloru Coded)orthagSWIMMING POOL ELECTRIC
he
the besb for the alleged exemption. Any violation of Section 70315 by any OUTLEI&SWITCHESSFIXTURES
@cc
applicant for a permit subjects the applicant to a civil peen lty of not more than
a five hundred dollars($500). NEWRMDENTIALELECTR SQ.FT. STORIES TITECONSTRUCTION
Z< ❑1,as owner of the property,or my employees with wages as their sale
compensation,w01 dothe work and thestruture is not Intended or offered for
y O sale(Sec 7044,Bugmss and P dmiom Code:The Contractors Llcerve law
)',y$$ does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RES.UMTS
EE.. who doessuchwork Mmselforthrough hisownemployedea,provided that such
Improvements are not intended oro(fered forage.If,however,thebuildingor TOTAL: Q
improvement Lssold withinomyearofcomplelomtheowner-WBderwill have s
the burden of proving that he did net build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
LJ k as owner of the property,am exclusively contracting with license — Fl-OOD ZONE APN
PERMIT ISSUANCE
contractors to construct the project(Sec.7074,Business and professions;Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilda or Improves thereon,and who contracts for such p(ojets with a FEE SUMMARY
c ator(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. BY Y_ N_
• Owner Date ,M RECEIPT Y
WORKMAN I have a COMPENSATION DECLARATION �.�S PER I IL TAX Y_ N_
❑i hereby affirm that I have a certifinte of consent to se141nsure,ora 3A RECEIPT Y
certificate ofWurkeri Compewatlon Insurance ora certified copy themef(Sec. GAS EA.SYSTEM] 40 A FEE Y N
3800,Lab C.) S ) Uid RECEPTY
CO
Y
F-1 Certified copy V(fled with the city
tlty GAEA.SYSTEM 1 1J BUILDING DIVISION FEES
Y
Certified copy is herebyturnty inspection divlslon. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
FNT�
CERTIFICATE OF EXEM P"DON FROM WOR KCRS' GRFASE.I , DEPAR �A�tl'
COMPENSATION INSURANCE DE
/ Date Reseda t#
(fhb section need nt be complied Bthc permit b(orone hundred dollars SEIVEB- - f'YL P
($100)orlem.) WATER IIEATf77 W/VENT/ELF-C1.R ENERGY FEE Y_ N_
1 certify that In the performance of the work forwhich this permit Is Issued,
1 shall not employ any person In any manner se as to become wbjet to the WATER SYSTEM/TREATLNG
Workers'Compensation Laws of California.Date PAID
O Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Reml t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provislors of the Labor TOTAL:
H W
Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING 'E
LU j deemed revoked.
W E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a U Ihereby afRrmlhat there itamrutrutlon lendingagency forthe perform TOTAL: ELECTRIC FEE S
M Z an. fthe work forwhlchthb permit is Word(Sec.3097,CIv.C.) PLUMBING FEE
02 Lenders Name
LL F Lenders Adamsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certitythat l have read thisapplicatlonand statethat theabove information
O W ism mt.IagreetocomplywithaUdtyandmuntyurdinanceands telaws PQLMTTISSUANCE FEES 11
M relating to building cnnstrution,and hereby authomm repreamatives ofthis
(_ N city to enter upon the above-mentioned property for Inspection purposes. JALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReCClpt#
V agaWt liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLI NG UNIT DO 10,ODO CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIA HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnatum of Applicant/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplicant or future building oavpat store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Remi t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lea lth and Safety Code on 25532(a)7 HEATING UNIT(OVER IfXIp00 BTU) TOTAL:
❑WYe VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
ill the applicant or future Wilding occupant use equlprrnnt or device
which emit havrdous ab contambunts as define by the Bay Area Air
.
Quality Management EtLtn* BOILER-COMP OHP ORI00,000BTU) � �^ 9e7
Yea o r i+
Ircv
haveadthehaousmaterials requims•
onts under Chapter 6.9iof BOMER-COMP(OVER IO),000BTU)
the California Health k Safety Code,Sections 75505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that it is my NEW RES]DENTIAL MECH. SQ.FT. '
responsibility to ntify the occupant of the rcquircrmnt.which must be cot
prior to lssua nce of a Cerlificate of 0�n,.
Owner or authorived agent Date TOTAL; ISSUED BY
OFFICE COPY