21583 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B.Ildfing Pro'ed Identification PERM NO.
Building Add...; C)e, G l8/'�aI� n
J 3
U.n sName: one:
CITY OF CUPERTIN0.BUILDING DIVISION q1e
Lie.No: APPLICATION / � `7
PERMIT �- 7- .
�S BNLDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL If
ted/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
1
Add.,. PFRh11TIS5UANCE 1:1 'E:1
❑
LICENSED CONTRACTOR'S DECLARATION
l hereby affirm that l am licensed under provision.of Chapter 9(comerme APPLIANCES-RESIDENTIAL JOB DESCRllrl ION
ingwlth Sect..7000)ef Division3 ofthe Bumnnaand PmfeW°a.Cede,end m
lice..Ts In�d o Affect. PANELS d
Llan IOW Llc M O� '�sem"'/
DUP TO 2DO AWS
ateContnmor /1FsL(71 p1[000 AMPS
ARCHITECT'S DECLARATION
q�+p❑O I understand my plamehall be used as public records. OVFRIOWAMPS -SQ.FT.FLOOR AREA $/SQ.FT.
i4 (3 Licensed Professional SIGNS ELECTRICAL
<61L`R� OWNER-BUILDER DECLARATION SPECIALC T
Thereby.!Rrmthallamexempt(romlheContreci°r'eLlcenselawlmthe
following reason.(Section 70315,Businessand Professions Code:An cityor
NALE
Fps' ceuntywhich Nquiresa permit tomretruct,alter,improve,demolish,orrealr IEMP.M
O6 any structune prior to Its Issuance,also require.the appBant for such perto �yyERDEBq
w O file a mgned statement that he b licensed pursuant to the provisions of the
w� Contractor's License Law tChapter9(commendStaten SWIMMING POODAMC
sion3oftheBu
uslneand Pro/emloru Codeorthat heisexempttherefrorat VALUATION
g the basis for the alleged exemption. Any violation of Section 7MIS by anyOUTLETSSWI7CIIESFU(TURES
0 applicant fora permit subjects the applicant to a civil penalty of no more than
$ five hundrednerof the property,
NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
❑eaaownwill
o(othe
work,andr my employes wlIhwageu/herrmle
C 6
compensation,Business
and kandions the Code:
emIntendedor offeredLaw '
O sale(See 7014,to ainow and Pro!®low Code The Contractors is Gceme law
$
who dedocs notntsuch
suchpply loan owner of Property who
envo a deorimprovnted com,that such
a whodoroauchworkhimeeBorthrough hisownemploym,provided that such OCG GROUP RES.UNITS
Improvements are not intended orofferrd!mule.if,however,thebullding or TOTAL:
Improvement isseld within one yearof completion,the owner-bullderwlll have
thB�Lurden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLCODZONE APN
u I,as owner of the property,am exclusively mntracd.g with licensed
contractors to corotmet the project(See.7054,Business and Professions Code: PERMIT ISSUANCE
The Contractor'.License Law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thenpct
thence, end who contracts for such project.with a FEE SUMMARY
cgB{T+ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B Ar P C for this rcawn
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
ser Date RECEIPT 0
WORKMANCOMPENSATION DI LARATION FIX.N PER , SCHOOL TAX Y N
hereby affirm that I have s artiBate of consent to self-Insure,ora RECEIPT N
cel HflmteofWorked Compematimlruurancemaanifkdmpythemof(Sea GAS EA.SYSTEM-1 0[7I7,Efs PARK FEE V N
3809,Lab C.) /�t
Pobcy B �eas 60 3 ens RA.sysroa.ovER a(EA) R��"
Com BUILDING DIVISION FEES
DCertified copy is hereby t - CREASR/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
e
Dainled copy Is(fled withh the
hthe city
inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date Recei tic
('Ihlsaecilon need not becomplded lithe permit b(Drone hundred dollars
(511less.I
1 ceriWATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
I arti(ythat In the performena of the work for which this penult b Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTCM/TRGTING
Workers Compensation laws of California. Date PAID
O Z Applicant NLM'RESIDENTIAL PLMB. SOFT. Date Recei tJ1
Z O NOTICE TO APPLICANT:If,After ma king t his Certificate of Gemption,you
should become subject to the Workers'Comperoatlon provhloro of the Labor TOTAL:
N
Code,you w=at forthwith comply with such provisions or this permit shall be BUILDING •E �•a
W > deerred revoked.
LU C CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z anceoftheworkforwhlch this permit is coned(See.3D97,Clv.C.) TOTAL:
U O Lenders Name PLUMBINGFEE
LL ~ Lender9Addmae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W, Iartlfythatl have read thisappllation and mztelhattheabovelnformation
a iscom
rrect.Iagree to complywlth all city and unlyordinances and mate laws PERMIT ISSUANCE FEE-PAID:
>- relating tobullding construction,and hereby authorize representatives ofthls
F city to enter upon the above-mentioned property for Wpeetion Purposes. ALTERORADDTOMECH.
Z Date ReCel tic
— e)agree to save,ImlemNty an d keep harmless the City of Cupertino P
a tlWblll1 es,judgrne ts,co rd..IA ewhkh may In anywayaccrue AIR HANDLING UNI'ITO 10,ODO CFM) SUBTOTAL:
A
i t said Ci In con f e grant tM1le permit.
I_ AIRHANDLING UMT(OVER IQOOOCFM) CONSTRUCTION TAX
Si oatureof Appliant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldleg occupant store or handle hazardous HEATING UNIT(TO 100,ODD BTU)
material as defined by the Cupertl Municipal Code,Chapter 9.12 and the Date Recei I
Health and Safety Ccde 37(a)I BEATING UNIT(OVER IDg000 BTU) TOTA s
Yea No
Til thea llant or future building Deco ant useequipment or devices VENTILATION FAN(SINGLE RESID)
pP B pISSUANCE DATE
which enter
anagem nt 'led?amiu dellned by the Bay Area Alr
Qu lily Management D'uWct7 BOILER-COMP OFIPDR 1W,IXp BTU) � ,D
Y. a'xl ' pp��
E] Y.read the haaa ow materials requlrementa under CM1apter 6.95 of BOILER-COMP(OVEI700,000BN) N
134 Czlifomia Health A Safety Code,Sections 2550$,25533 and 75534. I p� ry
ondesta thart fI ebuildingdoes not mrrcn ave a tenant,that It is my NEW RESIDENTIAL MECFL SQ.FT JAN l
respo i tyro nellfy them pant of the req nts which must be met �,Vtl 6a / 1n(J /'''�
prio once ACA It o ancy. 2 I N
er thorizedages Date ���� ..yaas��,�
TOTAL: ISSUEDBY-"
tLLJVsIAa
OFFICE COPY