20244 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address: 2 0244
a
m0 A A
G'I7�r/D/ �1Cffldl4/)Ii LSr7- 3//D CITY OF CUPERTINO-BUILDING DIVISION'lie •���
Gan"anr Lie.No: APPLICATION / PERMIT S�
BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lk.No,
Q'IY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSUANCE ❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that l am licensed under provWons of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DPSCRII'I'ION
ingwith Section 70000of Dt tsion3ofthe8usinessand ProfesslonsCode,and my S2�/f1
license is in tub force and dfect. PANELS G1
License Clam LION
Date Contractor `/
ARCHITECTS DECLARATION 201-t000A,MPS
Q,O❑ (understand enyptroahallbe used aspubBerecorda OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
(/ Llansed Pmfessionl SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIALCIACIRT/MISC
t" G Thereby affirm thatlamesempt(romthe Contranor'slicenae Law/or the
p following reason.(Section7MIS,Business and Profession Code:An ci or
countywhich 1 permit toconstruct,alter,lm y P !TEMP. ERR OR POLE INST.
anystiueurepror to its ssunceaborequirestheappllcanaforauh permitlofile a signed statement that he b licensed pursues to the prove lona of the EVICES
Gontnctors License law(Chapter 9(commencing with Section 70W)of Divi- POOL ELECTRIClon3 ofthe Busiess and ProfessionCode)orthat he is exempttherefromand VALUATION
_ the bash for the alleged exemption. Any vlolatlan of Section 70315 byany< appliant for a Perrot subject theapplkant too civil penalty afoot more t ban SWITCHESFIXRJRFS
five hundred dollars($S00). IDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their ante `SQFr. STORIES TYPE CONSTRUCTION
CX5a< compensation will Bothe work and thestrucbme is not intended or offered for
F❑ .1.(Sac.7042 Business and Professions Code:The Cont.d.es License law
j 2 does not apply to an owner of property who builds or improves thereon,and OCC.CROIJI' _KIS UNITS
G whodoessuchwork M1imselforthrough hisownemployeca,provided that wcM1
Improvements are not Intended oroffered forsele.If,however thebullding or TOTAL:
provemunt beoldwithinonyearofcompletiomtheowner-builderwillhave
th*,denofpmvingtha hedid nabu8d orimprovemrpurposeofsale.). QTY, PLUMBING PERMIT FEE FLOOD7ANE AWN
LI I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7074,Business and Profession Code: .V p
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENLa T-WATER(EA)
Wilds or Improves thereon,and who contracts fm such pWieats with a
�q➢t(ade a)Bcensedpunuanttothe Contnctm'e License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
OUTSI DE FEES
Owner DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Date
WORKMAN COMPENSATION DECLARATION RECEIT N
01 hereby affirm that I have a certificate of consent to eeif-insure,or a FIXTURES.PER TRAP SC TOOL TAX Y N
certificate o(Workers'Compenatlonlnurance m a certBled copy thereof sec. RECEIPT N
3800,1.bC.) GAS PA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
i
Policy
N
Caany GAS.E.A.SYSTEM-OVER 4(EA) RECEITN
Certlfind copy b hereby/umi.hnd. BUILDING DIVISION FEES
❑Certified copy Is filed Mth the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF E4lrT1PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE saas^T�I
(rhissection need nm becompleted ifthe permit lefor one hundred dollars SEWER-SANITARY-STORM FA.20UF1'. Va' Date Reeei t#
($100)mlyth in WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenor thatothe person
of theworkfo astobthis permit btoted, —
I ark ra employ any person in any mannerso u to become subject to the
Worlicant mpenaation laws ofGll(omt.Date WATIX SYSTEM/TREA7ENG PAID
C' Z Applicant
Z O NOTTCETOAPPLICANT:If,aBcr making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,FT. Date Recef t#
W
should become subject to the Workers'Comperwtlon pmvislon ofthe Labor TOTAL:
Codero
,you at comply with such provision ortht permit shall be
W > deemed revoked. BUILDING FEE
CL E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them be construction lending agency for the perform-
Z ance ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: / 'D� ELECTRIC FEE
U o Lender.Name 1 PLUMBING FEE ( _
LL F Undee.Address QTY. MECHANICAL PERMIT FEE 00
O w Iamilythm l have read thbappliationand statethat theaboveln(omatlon MECHANICAL FEE
b Correct.lagme to comply with allctty and county ordinance.and state laws PFRMRISSUANCE
a ty FEES PAID:
} N relating to building construction,and hereby authorize represemativea of this
'F Z city to enter u Pon the abovementloned property for imposition purposes. ALTER OR ADD TO MECH.
— (We)agree to ave,indemnify an d keep harmless the City of Cu penins Date Receipt#
against liabilities,ydgments,costs and expenses which may in any way amore AIR HANDLING UNIT(to 1gU00 CFM) 0
aga Wt said City in conc(u ence of the grant ing of this permit SUBTOTAL:
AIR HANDLING UNTT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of Applicant/Contractor (Ate IXILIUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant store or handle hazardous HEATING UMT(TO IW,ODOBTU) Date
material as defined by the Cupertino Murdelpal Code,Chapter 9.12,and the R eel t#
Health Mand Safety Code Townon75ding occupant HEATING UMT(OVEA t00,0008TU) A,sTTOTA - tl p
Will the sppBantorfuaremiturdg a defidby equipment or Bevies VENTILATION FAN(SINGLE RESID) ISSU�WATE .
which emit hazardous air contamimnb m defined by the Bay Area Alr
Quality Ma agement District? BOILER-COMP OHP OR 100,GM BTU)
4 Yea �No V ,( I-)yU
have read the hazy nut s materials requirements under Chapter6.95 of BOILER-COMP(OVER100,000HU) MAY
the California Health k Safety Code,Sections 25505,25533 and 25534.I
understandthat lithe building does not mmstly have a tenant,that itbmy NEW RESIDENTIAL MECH. SQ,FI,
responsibility to notify the occupant of the requirements whichmust be rret City of CBneriino
prior to Issuance a a Certificate of Occupancy,
1
Ownerorauthoriudagcnt Dace h✓
_ TOTAL: I55(/ED BY:\_I__ VlT-��
OFFICE COPY