20173 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect Idem - P TNO.
Budding Addree -
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TS O V R rz S CITY OP CUPERTINO-BUILDING DIVISION S—*)—
_ /_ 7 0
• c ntrador came: _ Lie.No: APPLICATION I PERMIT T
Q 5D� (05 BUILDING-F3,FCTMCAI PLUMBING-MECIiAMCAL CATEGORY CONTROLM
Architect/Engineer. Llc.Non
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I'FRh17TISSUANCE ❑ ❑ ❑
LICENSED CONTR under provisions
'
Iberebydfirnthatlamficensed under B.,1 ovblonsoffexxkx Cde,an rnc- APPLIANCESRESIDENI7AL JOB DFSCREPTION
IngwRh Sect ion 7000)o(DiWMon3 ofthe 8usinessand ProfeWmaC-ode,and my
license le In full fo d d(ed. PANELS
Llcens Ch LICI - . . I
Date'' VE Contractor ggonnr 1MINli f��?Pu) IZ
ARCHITECTS DECLARATION 201-10DOAMPS
ce0 OC I undentaed my plata shall be used aspublic records. OVER IO00 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
to d U Licensed Profenbnal STGNSELECTRICA
<<�6 K - OWNER-BUILDER DECLARATION SPECIAL CIli 7/n,
z 1.. 7� Iherebyafflren that lamexempt fromthe Omtrador'sLicense Law for the _
o following reesen.(Section 7031.5,Businm and Professions Code:Any city or
FZr" cauntywhlchmquimaper ttomomtmd,aller,Impmve,de=lWh,orrepair P. EITR I
q� anyetrocture prlortoits issuance,aborequireathe appllantfor such perrdtto POS �gIXq
t5 I+S file a signed statement that he b licensed pursuant to the provisions of the '
Q63u,� Contractors License Law fChapter9(mmmencingwlth&ttion7000)of IRA. SWIM4G E C VALUATION
O Mon3offlu Buelnmmfash
and PionsCode)orthat heexemmnd
p therefroa
0 S the basis for the alleged exemption. Any violation of Section 7(01,5 by any OU1LE Fl ES ' y/ O
YYY>lGG6JuJu1 applicant lots per tl bjedatheapphcanitoadvllpeairy otndmorethan lO )
R fi6undred dollars($500).
I,as owner of t he property, NEW R' AL ELEC STORIES TYPE CONSTRUCTION
�n p party,or my employees to with wages a there sole
compensation,7DK Bunwill dothewurk,andthertrudurebmontracort intended or offeredLaw
a Q sale(Bee.7046,Businsu an,PMmions Code:The Contractors Wcense Law
q >� does eel apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNTTS
EF• who donmch work himself or through his own employees,provided that such
Improvements are not intended oroffered for sale.If,however,thebulldlega j %TAL:
Improvement baold withlnoneyearofcompldion,the owner-Bderwillhave
tflgj2urden of proving that he did not build or Improve for purpme ofsakJ. QTY. PLUMBING PER IT FEE -
u 4 as net of the property,am exclusively mntrading wkh u-n— FLOOD ZONE APN
com adore to construct the project(Sec 7044,Business and Profmlom Code: PERMIT ISSUANCE
The Contactors License Law don no apply to an owner of property who ALTER-DRAIN k VENT WATER(EV
builds or improves thereon,and who contracts for such ptojed -
a with a FEE SUMMARY
cl5adorts)licensed pursuant to the Contractor's Lks enLaw. BACK PLOW PROTECT.DEVICE
Ll I am exempt under See mo
B h P C for this on
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECQ[xf M
WORK MAN COMPENSATION DECLARATION PD(TURFS PER TAM SCHOOLTAX Y N
❑I hereby affirmorkm that I have o Insurance
a c of consent to op rhino,(Sa RECm'f y
certlflate ofWorketi Compensation Guarana ora certified copy[hereof(Sec.
J GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3803,U RECEPT M
I'ollrya '— GAS FA.SYS'1'PM-0VER6(EA)
Cy
[J.Qr A/�rr�ehl A BUILDING D1v151oN E[0S
og
Cddi ect copy
le f the city
? Te GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
QCcdified copy b(fled with the city Impedian division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 700FT Date Recef t41
(Thissectlon need not becompleted lithe permit h fou one hundred dollars
5100)orles.) - WATER HEATER W/VENT/ELECT( ENERGYFEE Y N
I certify that N the performance of the work for which this permit is hard, '
I shall not employ any person in any manner m as,to become subject to the WATTR SYSTEM/TREATING
Worken'Compm,mon Lawaof Calfomb.Date PAID
0 Z Applicant NEWRESIDENTIALPLMB. SQ}T. - Date Recti t#
Z O NOTICETO APPLICANT:It, enticing entng this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be BUILDING FEE _ D
W > deemed revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercby dOk forwich this
eec. ,Civ.C.) perform TOTAL: ELECTRIC FEE
7 Z Lenders Name forwhlnh this permillshmed(Sec.3097,C1v.C.I
(� O Lenders Name - PLUMBING FEE
LL F ].enders Addmea QTY. MECHANICAL PERMIT FEE
0 W IsmIartlfythail have read thhappliationand Matethattheabove Information MECHANICAL FEE
S rmd.7 agrecto comply with all cityand muntymclinanmand Mate laws PERMTTISSUANCE FEES PAID:
} W
misting tobullding construction,and hembyaulhorize representatives ofthh
(- Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECIL Date ftecei tp
Z (We)agent to save,indemnify an d keep harmless the City of Cu pedBto
ago Inst llablllRes,jedgments,mstsand..pens.which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: JZ_ SO
g,L
agaiT.sdCIn conseqenceuoltbe granting o(thls permit. -
AIR HANDLING UNIT(OVER 10,000CFM) - CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7AA R DOLS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous IFEATING UNIT(TO I OO,ODO BTU) Date Recei tM
material as defined by the Cu Future Municipal Code,Chapter 9.17,and the
Health and Safety C a dion 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea TNo
Will the a ppilafuture
nt o building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANGE'DATE
which emit hawrdous air contaminants as defined by the Bay Area Air I ,raoa
Quality Management Dist d7 BOILER-COMP DLIP OR 100,000 BTU)
4Yes o 11
have read the hau ous Code,Section Chapter 95 of BORER-COMP(OVIR IDJ,000BTU) ['11A
the
understand
that
deny Code, otcurantlyh have
a tenant,
that it
vndentand that lfthc building don not currently haveatenanL that ltbmy NEW RESIDENTIAL MECH. SQ.FT. Ts .y
rnponslbillty to notify the occupant of the requirements which moat be out City BI rrhf?dino
prior to issuance of rtjlRateofOccvpancy.
Owner or authmized agent Date ISSUEDBY. x
TOTAL:
OFFICE COPY