20172 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PooKd Identification PERMIT NO.
Ba :
l0)17 1 FERNU,`oa0 20172
My Rom TDMaS I e CITY OF miCUPERTINO-BUILDINGDIVISION ^ y O
i` Ctnnm:N...103 6; o / Lk —f
.Na APPLICATION /PERMIT —(
~ "' BUfLDlN aDC—IRKAI PLIIMBINGMECIIANK:AL CATEGORY CONTROL
�\ AtchltM/Engineer. 'Lk. o:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Aaarm> PER.wnssunNCE ❑ ❑ ❑
LICENSEDCONTRACTORS WmsoATION
Iherteetton mtnat lam M=3ofunder prwandllrff l mir9(a snim APIrLIANCFSRESTDFNTfAL JOB DESCRIPTION
Ieer.I Secdon70W)o/OiviJon3ofthe BuJmaandProfestlana Code,and -
Ikenselaln(u}�fo:¢� effect `� PANELS
Liansc Glee -LLk.I lJ/' � GkiMNr fZ�P,411�
fAte�T-�(]_g_CoMnRor
r"/µa �/yasy
a '! ARCHITECT RATION 'DIPS
�2. Iundentard my pbrosha8 be used upub8c remda OVEE R 1000 AMPS SQ.FT.FLOOR AREA $/9Q.FT.
do
Lbensed Pro/eabnal SIGNS EI1ti TRTCAL
�� OWNER-BUILDER DECLARATION SPECIAL CIRCNT/M
E' G IherebyafBrm that l stn exempt fran the Contractor's License law for the
pppppp (olbwing rtason.[CI%HOrl7tti15,Buainm and Profmbna Code:Mytlty or
rl, .1y muntywh"requi apemdtbmmtmMalter,lmprove,demolhh,orrepJr TEMP.METFR IDLE S[.
Y'SS3 anypm=mprlortolbbsuamc aL requb theappNa tfmauchpemdtto
T�a0u I Els,a signed statement that he h Titers.d pursuant to the provisions of the POWER DLYI
Contrsdor's License Law(Chapter 9(commeneing with Section 700()of Divi- SWIMMING 1'CJO C VALUATION
of alun 3 of the But slnm and Profesbns Cade)or that he b exmp therefrone.nd pa/ N
F5 .alit the bash for the alleged esemptbn. Any Walatle.of Section 70115 by any OUTLETS f 0 v
.ppUontforaper sub}ctstneappec.nttoadvllpenahyofnM=mthan
{p� Ov undrod dollars(SM.Ud
I,as owner of the property,or ny employees with wages as their sole NE ESID04TILA STORIES TYPE CONSTRUCTION
mmperuatlon,will do the work,and the structure is res blended or offeredfor
Osale ISec 7014,B..ne and Prormbns Code:The Comrade?.U.Law
Ij$$ don rot apply to an owner of property who Wilda or improves thereon,andOCC GROUP RES.UNITS
whodoessucLwork hlmeelfathrough hleownemhat ployees,provided tsuch
improvcmemaarerwtintendMoroffetedfws .l(however,thebuilding or - TOTAL:
improvemem Essold within one yearofcompletbn,the owner-bullderwW have '
t"rd en of proving that he did net buud or improve for purpose or sale.). QTY. PL NG PER E
"L as owner of the proper ¢ u
property,am ehhdm
y ntrscting with licensed ROOD ZONE APN
mntndon to rovtruct the pro)ed(Sm 70K Busies®anti Prormbns Cade: PERMIT ISSUANCE
TTe Comndora License Law dm not apply to an owner of Property who AL]FR-DRAIN k VFM- ATFR�lw)
builds or imp.thereon, and who mmncts for such em peejwith s.
oQN�dents)Dar sea pursuant to the Cmrnetor:LirerAe Law. FEE SUMMARY
LJ I sm sump under See. 8 6 P C for this reason BACK FLOW PROTECT.DEVICE
Owner Dae
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT
❑1 hereby afMn that I have a artlfinte of consent to self-losurt,a a PIXIVRES PER TRAP SCHOOL TAX Y N N
cettfl teof Work<n'Canpe tbnlnsu mmacetW cmpythermf(Sec. RDCE'fF
38W,L.b CJ GAS F.A.SYSTEM-I BJC40UTLEIS PARKFEE Y_ N_ .
Pdby0 L& — RECEIPT.
GAS EA.SYSfEh1-0VER 4(EA)
Co y BUILDING DIVISION FEES
ert"" ocIp rrcb' h `d � � GREASE/JNDUSTRL WASTE nvrEIRCEPTOR PLANCFIECKFEE
Certified ropy h filed mth the city Inspection diviaon.
CERTIFICATE OF El(EMPTI).\'FROM WORKERS GRFASETRAP PAID
COMPENSATION INSURANCEg�,pRg,hND.,SgY SHAM EA. I' Date Reocf tp
CThb section need not be cm
opleted efthe m
peJt is for one hundred dollen
(MMorlesa') WATER HEATER w/vFxT/El.EclTc ENERGY FEE Y N
I mrtify tits In tits pedonmana o(tne wsak forwhich this pemUt b(.sued,
I shallnotemploy any person in any canner w as to become subject to the WATER�,�.�/.IR�.DNG
Wafer:Canpe.Uon laws of Cebranw.Dae PAID
Z Z NOTICE TO APPLICANT-.If,after mJdog this Certifoate of Evemptlon,you NEW RESIDENTIAL PLMB. SOFT. Date Recel tic
should become subkat to the Workers'Comperuabn previsbuu of the Labor TOTAL:
N CWe,yaumuafathwuh romply with such pmWalonaorihh permR"the BUILDING FEE 7.cV
deemed revoked.
W FaFa CONSTRUCTION LENDING AGENCY SEISMIC FEE Zh
a Ihereby afflrmlhat there is.construction lendingagerry forthe perform , ELECTRIC FEE
Z ance of the work for which this perMt b Issued(Ere.3097,CW.C.)
U O lender. m
.Nae PLUMBING FEE
LL Lenderanddn.a QTY. MECHANICAL PERMIT FEE
I anuythatl nave read this appllatbnand satetbat theatove lefomulion MECHANICAL FEE
O w
a hmnce.l agreetocomplywith all tltyard county,ondlnanresand state laws PERMIT ISSUANCE FEES PAID:
>_ relating to Wilding ronstruction,and hereby authorise nepossentatNn of this
N Z city to enter upon the abov rrontloned Property for irepedion Pu rposn. ALTER OR ADD TOM CH.
_ (We)agree to save,indemrdfy an d keep harmlm the City of Cupertino Date Recd tat
against liabilities,judgnenta ronaand expenses which soy,to anywayaevue AIR HANDLING UNIT(TO ID,DDD CFhD SUBTOTAL•
.gainstsaid Cuy ronanquenae of the gnntingdlNe permU. AIR HANDLING UNIT(OVER IO,"CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Jlgvturc of Ap est/GDUS Date IXIIAl1Sf HOOD(W/DUCT)
HAlARDOUS MATERIALS DISCLOSURE
Will the appl rd or future Wilding oaupant sort or handk hasardous HEATING UNIT(TO 100,ODO BID) Date Recei tat
nutertal as defined by the Cupertino MuJdpal Code,Chapter 9.1 Z and the
Health and Safety Cd4c,".255320)? HEATNG UNIT(OVER IMBED BTU) TOTAL: _
❑ Yrs No
Wlllthe applloM NreWllding«cupantueeequipment ordevba VFNIILATIONFAN t51NGLE RESiD) ISSUANCE DATE
which emit lusardous air ovdaMnu ma as deRnsd by the Bay Area Ab n—a -1
Q.1ity Mauugemem DM 7 BOR.PR-COMPOIB'OR100,MEITU)
4Yes
have read the haze ous matcrlab requlrtmenh under Chapter 6.95 o! BORER-COMP(OVLR 100,0008711) Ir
the Ulit.m HealthkSafetyCada Se ..75505,25533.nd755M.I
u nderstand that ifthe WUdingdoes notaroentlyh.veer tenant that it is my NEW RESIDENTIAL MEIN. SOST
responsibURy to notify the odvpam of thenqubemems which mut be and city of rsol^P.lf10D
prlanto bswnmd CrAtfi Ie of Oeoupary.
err err iutM1ori' TOTAL agent (Ate ISSUED BY:J
If
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