19882 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
BulklmgA dress: I� 19882
! I1 l�,I 6 -e _
v a acre: •�J Phone: A A A . '
't:55a CITY OF CUPERTINO-BUILDING DIVISION
ContraRm'e Name: Lic.No: APPLICATION /PERMIT I [
BUILDING-ELECnUCA PLUMBINGMECHANICAL CATEGORY C
Archlte / glneer. k.Na - ��•
�l ` Gi x1D QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address s onMIPER ITISSUANCE ILoD
LICF.NSEDCONwduC erpS LARATION '
[hereby 10A71 thatlam lkrnseduederprovlalavofCha...Cmmmrnc APPLIANCESRESIDENTIAL )OBDFSCRB'EION
Icon.isI.fug? andleffeR��tL uelnessandPro/eaiovCode,and my PANELS ,
ice Case Lica YT' �7=z)& L
ate Contractor
ARCHITECTS OF
ION IDI-i BOB AMPS
aO ZpZO I understand my plan ahall6e used u c records. OVER i000 AMPS �.FC.FLOOR AREA " 5/SQ.Ff.
u Licensed Professional SIGNS ELECTRICAL ^ . - � /7..1'(/I/>•
` .
OWNER-BUILDERexempt
mptfro DECLARATION $I•pC1ALCIX "T/111 �flv`� .-. ■
Zt.,rGlfa Iherebya(flrmthat lamexempt(romthe Contractor's Lianas Law for the _�
fallowing reason.Oec2lan 7miS,Business and Professions Code:Any city or
r ^!q+j countywhkhrequbvapermltWmvtmd,alwr,Imprme,dennlbh,orrepair TFMP.MEITiR ORI'O
:.t anystruchire prlortolteissuance,also requlreatheappllant forsuch permit to POWER DEVICES Q apt D
file a signed statement that he b hemmed pursuant ro the provi,iov of the (f�
3 u, Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL SOELECTRIC VALUATION S Non3oflhe Buslnessand Pmf.kx.Code)orthal he b exempt therefromand -
O the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant for a permit subjects OUILETSSWITCI-[ESS the applicant to a civil penalty of nor more than
five hundred dollars($SM.
'9.•' ❑L as owner of the property,or my employee.with wage.a.their Bole NEW RESID L SQ.FT. STORIES TYPE CONSTRUCTION
com
pevation,will do the work and thealrocture boot Intended or offered(or
O sale(Sec.7D1#,Business and Pm(essiov Code:The Contractors License Law
does not apply to an owner of property who builds or improve&thereon,and EE OCG GROUT' RFS.UNITS who don.uch work himself or through Msawnempicyen,provided that such �� _ _
Improvements arc not Intended orotfered(orale.I(however thebulldlegor TOTAL:
Improvemenlbaold Mthlnomyarofcompldion,theowner-bWlderwW have
tlLlfurden o(pmving that he did not build or improve for purpose ofsale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
u1,a owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
r�
contraction to construct the project(Sec 7014,Business and Professions Code.
The Contrsttar'.License law does not apply to an owner of property who ALTER-DRAIN&VENT•WATER(EA)
builds or improv. ren,theoand who contracts for such pgojects with a FEE SUMMARY r
cgR((admW Ban.edp..ant to the Contractor's Llan.Law. BACK FLOW PROTCCT.DEVICE
LJ I am exempt under Sec B 4 P C for this reason
Owner - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEErf B
WORIOdANthat COMPENSATION DECLARATION F0(TURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have• Insurance
an of con.Rt to op4tnsure,ora RECEPr#
certificate.(Workers Compewtlonlvuranceoracertlfled mpythermf(Sec.
3800,lab CJ GAS EA SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polity N DINGRECEIPT N
GAS Eh.SY5777H-0VERd(EA)
Ca�mpan4, t BUILDING DIV]SION FEES
I Zified copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rL�-1 Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRV' PAID 441 5W2Q
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2tpFT Date Re1Z'f t# �8•�
(fhi..ction Reed not be completed if the permit b torom hundred dollars
($100)or less.) WATER HEATER W/VENT/F].FCTR - ENERGYFEE Y N
I certify that In the performanceaf the work forwhich this permit is Wued,
I.hall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
WorkerCompensation Laws o(California.Date PAID y-�
O Z Applicant NEW RESIDENTIAL PLMB: SQF. Date Remi t#�y�'d2
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Wmi,am'Compevation provisions of the Labor TOTAL: '
N Code,you mu.tforthwith comply with such provisions orthb permit shall be l
49
W deemed revoked. Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
LU C
Z nIhcrobyefl hattherebamvtructlon lending agency for the perform TOTAL: ELECTRIC FEE 0�
oce of the work(or which this perMt is Issued(Bsc.3097,CN.C.)
L) O tender.Name - �` PLUMBING FEE Q6
H Lenders Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEB O6,
O W [cert..diftlhavcreadthbappllcitlonandurtethat yordinances ndstat informationMECHANICAL
C bcotosgreetocomplywith andcityrandhereby
auhoriae lnancesbetio.state laws I'FRMTTISSUANCE ZC'b PEES PAID:
} W relatingoenterulldint mvwctlon,anddproprtyotl in reprc.nntivo o(thb
H Z
city toenlerupon
sisvhe above-mentlonedpP.E.h. or Ins h'.yCijrf C..s. ALTEROR ADD TO MECH. Date Recei t#
V — nae,ledemNty an d n e harts he City y Cup cerce - P
nstllabWliea, dgmenb,cos expen wit yin any wayeccrue AIR HANDLING UNIT(Tr010,000 CFM) SUBTOTAL:
ag t aid City con a of the it g t.
AIR Fv,brouNc UNIT(OVER Io,DBocFM) CONSTRUCTION TAX
ppuaet/Contr Date -7, EAHAUST HOOD(W/DTX I) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS CL URE
Will the applicant mfuture building occupant store or handle haiardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
H,xlth and Safety Cod,Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU)' TOTAL: NTZGf
RYa 11 MN.
W the applicant or future building rampant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hau rdous air contaminants as defined by the Bay Area Air BOILER-COMP pFEa OR t00,00pB
ellty Management District? BTU) RAM . ,
Quin Y. n�1 No �('��011lc+`!:
?have read the
eath&SattyCoddab mors 25enbund .rd2553.1 of BOILER-COMP(OVFR 100,000 BTU) O
the Californierst.rdt Healthk building
Code,Sections ttlyh veal and75506.1 - �s_r t .. egg . .
under.tandthat if the notify
the occupms of the require endiwhich Hosni bray NEW RESIDENTIAL MECH. SQA. f1U1 3 j
responsibility to natlfy the ocmpanl of the requircmenta which mus be mot
prior to Issuanceof a Certificate of Occupancy.
' I Of ('ilort.�iRo�
Owner or aulh crud agent - Date - TOTAL: ISSUED BL
Y:v
s
OFFICE COPY