20171APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
t I) 9 VoRKSN/Rrz
PERMIT NO.
/"I O a�
G I
ra Acame: one:
R06 VL7_ Wfff7%rzN
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING.ELECTRICALPLUMBING-MECFIANICAL
A A
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LI='N°�
d°' MA 8y
CATEGORY CONTROL N
Archhoot/Engineer. Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
Ki 1,111�1
❑ ❑ ❑
LICENSED co,TRACTOR'S D[CLARATION
I hereby affbm that l am licensed under provisions of Chapter 9(rommen
Ing with Section 7000)of Dlvud on3ofthe Busirussand ProfesslonsCode, and my
license is in fu (o dfect. r
License CkaeLie.N IOr9'7O ef
Contractor
ARCHITECT'S DECLARATION ` A
IunderstandmyPlana shall be used As public eemrds.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason, (Section 70315, Business aed Professiam Code: Any city or
countywhich requlma a perm(t to mmtmM alter, impmve, demolish, or mpalr
anystmqure prior to Its Issuance, alsorequlres theappliant for such permit to
file a signed statement that h to licensed pursuant to the provisions of the
Contractor's License 1aw (Chapter 9 (commencing with Section 7000) of Dlvl-
and Professions Code) or that he k exemptthercfromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjec athe applicant to a civil Penalty of not mora IM1an
dollars ($50Q.
(Ives I, as
❑l, as owner of the property, or my employees In with ween se ffelr sole
compensation, wgsheess work andtons Codurc Isnot intended orofferedfor
ole( Bee. 7096, to an oaand Professions Code: The Contraorimp Roes License Law
docs nossImInt apply torn imselofp rough who Wllds mpoyees,pvesthercoRand
whodoesthrough hlsown e. If,h we providedthat such
ar workhimselfmse intended
Improvementsarenot Intended earotcdfanale.ILh er-p flder ilI have
Improvement lswld withlnoneyearofrompldbRthownerbuBderwlll have
tlILJ�urden of proving that he did not build or improve for purpose of Aide.).
"I, ae owner of the property, am exclusively mnlratllng with limned
mconstructPERMIT
ntractore to the project (See 7044, Business and Professiam Code:
The Contractor. License Law does no apply to an owner of property who
builds or Improves thereon, and who contracts for such plojects with a
cgpJladreL.) licensed pursuant to the Contractor. License Law.
I_J I am exempt under Sec. B k P C for this mason
APPLIANCES -RESIDENTIAL
J08 DFSCRBTION
-
1" /NIFY
"-
PANELS
2014000AMPS
OVER 1000 AMT'S
SQ. FT. FLOOR AREA
s/9Q. Fr.
SIGNS ELECTRICAL
SPEC CIRCUIT/M qC
.TFT `GR NST.
EVI
SWlN4G PCKU'E
SVANelon3oftheBusiness
Ol1TLE.B
q VALUATION
jsq�' I a O
NEWR ENTIAL RL TR__SQ.FT.
STORIES
TYPECON5TRUCTION
TOTAL:
QTy. PLUMBING PERMIT FEE
OCC. CROUP
RIS. UMTS
ISS(IANCE
ALTER -DRAIN & VFM-WATER (EA)
FLOOD TONE
APN
FEE SUMMARY
BACK [TAWI'ROTPLT. DEVICE
r
DRAINS. FLOOR ROOF, AREA, COND.
FIXTURES PER TRA'
SANITARY Y N
RECEEPf N
Owner Dare
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have oluumcertificate of consent to seytheum, ora
certlflate o(Worken'Compematlonlmurance aacertifkd ropythemaf(Sec.
3800, Lab C. d G
Poliry N
SCHOOL TAR Y N
RECFIPf N
GAS EA. SYSTEM.1 INC.4 OUTLE75
PARKFEE Y_ N
RECENT M
CAEA. 6 (EA)
S
Com
CCnNed copy k filed with tM city impecilon division.
CERTIFICATE OF EXLTIPTION FROM WORKERS'
COMPENSATION INSURANCE
(TM1 ' Iaxxlon need not M completed I(the permit V (Drone hundred tlollary
(St 110)ortess.)
Icon( emptiest he performance zrnnerhe week so As to which this is leo theed,
1 shall not employ any person In any manner n ae to become abkd t° the
Workeri Compensation Iowa of GII(arnk. Date
Applicant
NO'110E TO APPLICANT: R, after making this Certificate of Exemption, you
At ould become subject to the Workers' Compematlon prov4bns of the labor
Code, you It forthwith comply wit h such provisions or this permit hall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyaflmthatthere is construction kndingagency forth perform-
once of the work for which this permit 1s issued (Sec. 3097, Cie. C.)
Lender'. Name
L-ender.Address
I mrtifylhatl have read this application and statethatthe above information
Escorted. I agree to mmplywith all city and county ordinances and state laws
relating tobuliding mmtrudlon, and hereby authorise representatives of this
citytoenterupon the abova-mentloned property for Impectlon purposes.
(WA) agree to save, IndemNfy an d keep harmless the City of Cupertino
aga Wt lkbBltks, judgments, cone And expenses which may in any wayaccrue
.6t said City I. on ence of the granting of this permit.
L0
BUILDING DIVISION FEES
DI
GREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Remi t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 20(IFT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Da1C Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
BUILDING
O0
SEISMIC FE'
TOTAL
ELECTRIC FEB
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEB
PERMITISSUANCE
FEES PAID:
ALTFRORADDTOMECH.
Date RCCCI t#
AIR HANDLING UNIT ITO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 1R000CIM)
CONSTRUCTION TAX
ntr"'��
Signature ofAppllan o lrador Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as ciefined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Iicalthand Safety Code lion 25532(a)7
❑ Yes WN0
Will the Applicant o future building occupant use equipment or devices
mih
which et zardous ale contaminants as defined by the Bay Area Air
Quality Marugement Dist dl
4Yes
hvemad the lb. tom.ledalerequirementsunderChapter6.95of
the GIIlomia Health &Safety Code, Sedlom 25505, 75573 and 75536. I
understand that if the building does not cumnlly have a tenant, that RL, my
responsiblllty, to notify the ottnpant of the requimments which =At hat met
priorto Wu ante aCxnifiateof Ocmpanry.
Amer or authorized agent Date
IXF1AU57 HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(TO100,00013TU)
-
Date Recti f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUN�61t1ATE
11 LLQ
i.t'( (f I (y J
C1t9 Qf ("Illy}i0f4'
ISSUED gY��aI��VL Ii'CL�
/
BOILER -COMP QITPOR 100,000 BTU)
BOILER.COMP(OVER IW,000BTU)I
NEWRFSIDFTALMECII. SQ.FT.
TOTAL:
OFFICE COPY 4�"y