20838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Pm'ed Identification PERMIT NO.
Building Address: {s 7 , g]O O
3/ SUI �e C- G o
Uwnerarvarre: \ one:
E ,5 �. — BZS' CITY OF CUPERTINO-BUILDING DIVISION
contract°:• a Lk.No APPLICATION I PERMIT
BUILDINGUDCTMCAL-PLUMBINCMECHAMCAL CATEGORY CONTROL#
ArchltM/Enginttr. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
IPERhETISSUANCE Z5:6 ❑ ® ❑ ❑
LICINSEDCONTR candor provisions
I hereby ion70that t ivsionsedunderprosiand rof efeaEor,9le,and APPLIANCES-RESIDENTIAL ]p9 DFSCRUr1'fON
It...I.I.fon 70007 of Division ofthe Busineuand ProfesslonsCode,and my
lirens is In full force id effect PANES Grew
DaeLiceClan Llc# e_ Se—V -
Date Contracror (�
ARCHITECTS DECLARATION 301-100UAMPS
re0 O I understand my plane dull be used u public records. OVER 1000 .FT.FLOOR AREA 5/SQ.FT.
Licensed Professmnal SIGNS E L
�«< OWNER-BUILDER DECLARATION SPECIALCIRC
zp, [hereby a(firtnthallam exemptfromthe Can[ractor's Lkenss[awfa the
following reason.(Section 70115,Business and[Professions Code:Any city or
CEI" countywhkhmquke•aper tmcoratvcl,alter,bnpmv demolbh,orrcpalr TEMP.# ST.
E
anystruaure priorto its lsesance,alsorequlreatheappllunt forsuch permit to POWER Li
4,K ' file a signed eutmarent that M b&lkcmed pursuant to the provisions of the
O w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl-
30 elon3 ofthe usiness and ProfessbruCade)orlhat he k exempt therefromand NG C VALUATION
B
O_ the basis for the alleged exemption. Any violation of Stolon 70315 by any O F7X•LUR
666 Ck?c
applicant for a permit subjects the applicant to a civil penalty of not..than
y$
fl v undred dollars(550X0 NE AL ECTR STORIES TYPE CONSTRUCTION'
I,as owner of the property,or my employees with wages as their Bole
co p.nutlon,willdothework,and lheetrucNre b not intended or ofZIMor
`tom' q ale(Sec.7044,Business and Professions Cade:The Contractor's License Law
K $
does not apply to an owner of property who builds or improves therem,and OCC.GROUP RFS UMTS
i whodcessuchworkhimselforlhrough hbownemployeee,provided thatsuch
Improvements are not Intended oroffered forule.I(however,thebuilding m OTAL:
Improvementis•old withinoneyearofcompiellorytheowner-builderwlllFuve
tl,RJurden of proving that he did not build or Improve for purpose of ale.). QTY. FEE
FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Profmiom Code: _
The Contractor's Limrae Law does nal apply to an owner of property who
builds or Improves thereon, m and who contracts for such pkojewith a ALTER-DRAIN VENT-WATER IEA)
mjtractor(e)Band pursuant to the Contractor's License Law. FEE SUMMARY
LJ Im t u � B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Ow Nr Date RECEIPT#
U
❑I hereRXMAN COMPENmfiaSATION DECLARATION FD(TURES.PERT. P SCHOOL TAX Y N
by ffi.that I have a rtlte of consent to self-mam re, a RFGE PT«
certificate ofWorkers'Compe:aation Insuranre ma certified copythereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab C.)[PCeRECEPT#
Polity# GA&EA.SYSTEM-OVER d(EA)
Com any BUILDINGDIVISIONFEES
allied copy b hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F—ICertifted copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI. Date RCCCi [#
(Thtasectian need net becompieted If the permit b forom hundred dollars
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I mrtifythat in the perkurranm of thework(.,which this permit Is saved,
I shall not employ any person In any mares,no as to become subject to the WATERSYSTLM/TRFATING
Worker(Compensation Laws of CaRfomla.Date PAID
Z Z ApplicaNOTICE
NE'WRESiDENTIALPLMB. SQ.FI'. Date ROCCi [#
O NOTICE co esub)eAM:ILami making lhOmationkrowisorm oftate of eLyou
should become subject to the Worken'Comperuallon provlsbru.(the Labor TOTAL:
Q) Code,you must forthwith comply with such provisiom or this permit shall be BUILDING ,•
W C deemed revoked. AGENCY SEISMIC FEE
CONSTRUCTION LENDING ACCY
M Ihercbyaffirmthatthem isacomwctionlendec.3097,Chi.
C.) perform TOTAL: ELECTRIC FEE
� Z once.(the work for which this permit is L.eued(Sec.31197,Clv.Cd
O O Lender.NamePLUMBING FEE
1L I— Lendre.Addre.a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 certitylhat I have read thleappliatlonand statethatthe above information PERMIT ISSUANCE FEES PAID:
a Incorrect.Iagree to complywith all cityand county ordinances and state laws
>. relating tobullding construction,and hereby aulhomse representatives ofthis
(_ 2 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino
O against liabilities,judgments,was and expenses whkhmay in an way mme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
[rot aid Cityln s erre oflhe .^ting fthl.permlt.
� AIR HANDLING[INR(OVER]0,000CFM) CONSTRUCTION TAX
wtiare Applicant/Contrador I D to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WII eappllantor future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material ere defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Cade SMion 25533(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
M Yes No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REED) ISSUA DATE
s which emit hacardous air mnt.emeara.me dell rind by the Bay Area Air gO[LER WMP ptBPOR t00,000 B'Hl! I ���
Quality Management DIsiHd7
r M Yes
Thaave MN.read vin read thehaza`r Nmaterials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) IIIc
the California Health k Safety Code,Sedlons 25505,25S33 and 75534. I V ll
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECII. SQ.FT.
rs ruibRi to not the occupant of the re irements which roust be met f r
priori to Issuance of a Certificate of Occvpanry Clbf P II�9diry
Ownerorauthorivd agent Date TOTAL: ISSUEDB
OFFICE COPY