19848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proved Identification PER?ATNO,
Building Addreas:
218sz W060 15UR3 DRIvC 19848
hers ante: Phone:
MRL COM kW&PORD 2 (p5" CITY OF CUPERTINO-BUILDING DIVISION
C.mrador's Name: Ldc.N. APPLICATION I PERMIT
r! Ttrio pl&rAOId6G 6*e BUILDINGSLBCTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL
Archin /Gglneer. Lie.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add... - PERMIT ISSUANCE ❑ ❑ M Y ❑
LICENSED CONTRACTOR'S DECLARATION I`FIO
IMrcact10affirm lMtf iv licensed oftheerloessan Prefesapler9(mmmme- MPLIANCFSRESIDRM'fAL JOB DFSCRETI N
Ingwe Is In fonoreat ofd effect .(theBuslneesand Pro(essloneCode,and my
license la In(u rce and d(ect. PANELS
Llunec Glass Lk.AZ 4 O �s
Date w Cnnlnclor -p( m Ej um 8lrvG- -pip
E"
ARCHITECT'S D.CLARATION 201-1000AMPS R
QC I understand my phre.hallbe used u public records. OVER IODO AMT'S SQ,FT.FLOOR AREA $/SQ.FT.
O
d Llunse i professional SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION
!n`a SpECULCIRCUIT/MLSC
ZE' Thereby a(Orm that]cum exempt from the Contractors License Law for the
following reason.(Seddon 70115,Business and Professions Code:Any city or
O' TEMP.Mh1PRORPOLE INST.
�4 countyodure requires.Lawancealmoruuires 1heaprovgdemaWh,ormpair
mitt
En]
aWduretatemepricato ltshat he
pursuant
to the provisionormuch s
of to pQWp,R DEVICES
IRS Elle a signed statement that M b licensed pursuant to the proWelors of the
Dµi. Contractor.License Law(Chapter 9(commencing with Section 7000)o(Divl- SWIMMING POOL ELECTRIC
.ion 3ofthe Businessand PrefeaslonsCods)orthat he is exempt therefromand VALUATION
5 the basis for the alleged exemption. Any violation of Section 70)1.5 by any OUTLETSSWITCHFSHXTURES
applicant for a permit subjectathe applicant to a civil penalty of nor more than
o Ove 1.aro owner of
NEW RESIDENTIAL ELECTR SQFI'. STORIES TYPE CONSTRUCTION
EEE���111111 ❑I,as owner will
of property,or my employees with wages as their sole
he
.1.(Scompensation,K Dumb, thework,
rofeas om Code; is
at Contrendedactors
or License
d for
Law
D dole(Sec.apply
to alnow andf prop"
rop oro Code:TM Contractors License law
�$ doe.not oeapply tornowner offthroug hiswho builds
emplrlmprwvided roryuch OCC.GROUP RES.UNITS
and
who doe.such
nts amwork himself ndedr offerhieown e.If,ho eprovidedthat such
Improvementsarcnot Intended earolco plsale.ILhowever, deer ill have TOTAL:
Improvement bwldwithln oneysaofcompletion,lM owner-bullderwill have
OAltarden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE STOOD ZONE APN
U S as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does nut apply to an owner of property who ALTER-DRAIN A VENT•WATER(E.A]
Wilds or improvejects s thereon,and who contracts for such p(owith a FEE SUMMARY
ctactm(s)Bernard pursuant to the Contractor.Lima.Law. BACKFLOW PROTECT.DEVICE —••—•-••-.-
L I am exempt under Sec. B k P C for thin reason
OUTSIDE F17ES
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N
Owner Date RECEIPT N
WORICHAN COMPENSATION DECLARATION O FD(TURES.PER TAM �[�00 SCITOOL TAX Y N_
-( I hereby affirm that I have a certificate of c...ant to self-insure,ora RECEIPT M
c Ifialeo(Workers'Comper tlonlr mnmoraunlfiedmpythereof(Sec. GAS EA,SYSTEM.1 INCA OUTLETS PARK FEE Y N
38001 Lab CJ
Policy x RECCAS-F.A.SYSTEM-OVER 4IRA) DING DI N
Com any BUILDING DIVISION FEE
nCertified copy In heed with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b(TIM with 1M city IrupMlon division.
CERTIFICATE OF EKb-MPTION FROM WOR KERS' GRFASRTRAP PAID
COMPENSATION INSURANCE Sh1VEWSANITARY-STORM FA.200FT. Date Real l#
(Thlssectlon need not be completed if the permit b forone hundred dollars
($l W)mlea..) t WATFR HEATERW/VENT/FLSCTR ENERGYFEE Y _ N
Icertllythat in the performance ofthe work forwhlchthie permit is bared,
I shall not employ any perwn In any manner so as to become subject to the RIOTER SYSTEM/TREATINGWorken'Compensallon laws a(Cali(o{nla, Date PAID
-
Z Z Applicant NEW RESIDENTIAL ELMS. SQ.pT. Dale ReceI t#
NOTICE I'O APPLICANT:If,after maHng thin Certificate of Exemption,you
should become subject to the Workers'Compensation Provblors o(the Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthls perndtshall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL (hereby affirm that there Is a corstroction lending agency for the perform. Od ELECTRIC FEE
D Z ance of the work for which this pereent b WTOTAL: J'Q
ued(Sec.3097,C1v.C.) r
U O I.nder's Name PLUMBING FEE 72,9V
i— Landees Addrcn, QTY. MECHANICAL PERMIT FEE
O U lanti!ythatlhavemadthbappiiationandkatethattheaboveleformation MECHANICAL FEE
G 6cormd,I dgem to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE-PAID-
>. relating to building constroctlon,and hereby.whoriae mpresentation;.(this
(— Z city to enter upon the above-mmontloned property for for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReCeipl#
V against liabilities,jodgments,"sand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR ILANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Sigwtures(Applicant/Contractor Data EXSAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardoue HEATING UNIT(TO 100,000 BTU) Date Recei l#
matcrlai as defined by the Cupertino Municipal Code,Chapter 933 and the
I lealth and Safety Code Seelion 25532(x)? HEATING UNIT(OVER 100,000 BTU) in TOTAL:
R❑
Y. No
ill the applicant or loom,building occupant use equipment or devices VENTILATION PAN E3INGLE RFSID) ISSUANCE DATE
which emit harandousair contaminant...defined by the Bay Area Air APR r�s 1 u 6-4t)i
Quality Management District? BOILER-COMP DHP OR 100,0(10 BTU) A N
[?Yea W®No
have read the hazaido. materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,D00 BTU) µ
the California Health k Safety Code,Sections 75505,25533 and 25536. 1 Yd
understand that tithe building does not currently have&tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT. _
responsibility m notify the occupant of the requirements which moat be met
prior foil/;Wate of Occupancy. L/)-
Owner or authorized agent Date TOTAL: I ISSUED BY. . `V•,•Jr(J Q„Q�,�Ps,
OFFICE COPY