23416 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
Building Project Identification TNG.
Building Address:
VIII LINO S - f 23416 '
where ams: �s one:
1M t Lrw CITY OF CUPERTINO-BUILDINGDIVISIONr �
61,21,1c,N. APPLICATION / PERMIT 3 CD —7 ,['J
'
-"- ����• 30 BMLDINC-ELECTMCAT nUMBING-MECHAMCAI. - CATEGO Y, CONTROL Z
Arci/eci Engineer: .f tea/ Lie.N. O �/
1 JQfnf f!�A�a� BUILDING PERMIT INFO
� y QTY ��ELECTRIC PERMIT FEE
Address: so/w1 's SV PERM(TISSUANCEf�`/��� ❑ ❑ -❑
LICENSED CONTRACTOR'S DECLARATION Ys
[hereby efftrmthat l am licensed under provisions of Chapter 9(comenesu, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Dlvision3o( eBusl errand ProfessionaCode,and my
Ilcenselslnfu0 andeictlffect. 'jn PANES
License ss La� � !�
Date Cantracmr W
CHITECPS A N 201-1000AMP9
q�v000 Iunderetand my pWro ahaO be useas publicrecoNe. OVERIWO AMPS SQ.ET FLOOR AREA S/SQ.FL
U(0 Ltoonecd Pmfesslovl SIGNSELECTRICAL
fn`¢<LGS OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC •+-(/
7p, 4 Iherebyaffirm that l am exempt fromthe Contractor''sLicense taw forthe
pp following reason.(Section 7071.5,Business and Profession.Code:Any city or
C i"W counlywhich requires a pernotte censtnot,alter,improve,detoolbh,orrepa,r TEMP.METER OR POLE INST.
� � any structure prior to its issuance,also requires the applicant for such permit to pOWrOR DEVICES
r file a signed statement that he b licensed pursuant to the provbioru of the
Comment'.License Law(Chapter 9(rommend.g with Section 70W)of IRA- SWIMMING POOL ELECTRIC
Osion3ofthe Busffi se, nd Profemlom CWe)arthethebexempttherefromand VALUATION
M S the basis for the alleged exemption. Any violation of Section 7031.5 by any
G - applicant fora permit subjectathe applicant to a civil penalty of not more than Q D
M
GUILE fiF11,as owner of the pro NEWS D AL L STORIES - TYPECONSTRUCTION
QQQQQQ I,act owner of the properly,or my employees with wages as their sole
compensation,willdothe work and thestructure is not Intended or offered for TE q
O elle(Sec.7094,Business and Pmfessioss Cade:The Contractors License Law
3� doe.not apply to an owner of property who Wilds or Improves thereon,and RES.UM'fS,
EE
.he doesauch work himself.rthrough his own employees,provided that such (x GROUP
improvement,are not Intended oroffered forsale.If,however,the W Ilding or
Improvement issold withtnoneyearofcotople lon,iheowner-bu0derw111 have -
tn of proving that he did not Wild or Improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE
MAPN.
s owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor.to cori.tmct the pmJttt(Sec.7094,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who yy�g-DRAIN k VENT-WATER(FA)
Wilda curro
Impvot thereon,and who contracts for such pwiects with a
cgtRTador(N nN
Rcesed pursuant to e Contractor's License Law. FEE SUMMARY
u I am exempt under Sec B A P C for this reason BACK FLOWPROTECT.DEVICE '
OUTSIDE FEES
Owner - DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N
Dare
WORKMAN COMPENSATION DECLARATION RECEIPT,If
FIX'TURHS PER TRAP SCHOOLTAX Y- N
I](II hereby affirm that I have a certifi ate,df consent to se0dnsure,or a RECEIPT p
� i to ofWorkers'Comperieadan Iruurance oracertiflcd copythemof(See.
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE y N
Poliry M RIC=p
Com any M GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
CCertlfled copyb hereby ml9hed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE a
Certi(led copy b tiled with 11.city inspection division. ,( 0
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID_3"�"h— '�J/ '7T2.7 U
COMPENSATION INSURANCE SEyERSAN17ARY-STORM EA 200PT Date „'O=RReeceai—t#
Cfhlasectbn need notbecompleted lithe permit b(orone hundred dollars
(9100)orless.) - WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
lcenete poyanat in the p Eamon
heworkso an toohthhpermltbbo theccl, —
I shat not employ any person In any manner so as to become subject to the
Workcra'Compensatlon Laws of Cah(omia..Date PAID
O Z Applicant WATER SYSTEM/TREATING Date Recei t#
Z 0 NOTICE TO APPLICAN 1:if,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FI'.
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
W Cade,you moat forthwith comply with such provisions or this pemdtahail be ..] `t•�Q
W j deemed revoked.
BUNG FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
tL Hurcbyaf@mthat thembeconntmction lending agent fortheperfarm ELECTRIC FEE
M Z ance ofthe work(car which this permit b Issued&c.3097,Civ.C. TOTAL;
L) fenders Name PLUMBING FEE
LL F Lenders Address QTY: MECHANICAL PERMIT E MECHANICAL FEE
O W Icertifythatlhavereadthbappbcationandrtatelhattheabovelnfortoatlon -
CL bcorenctI agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize represenlal,ves ofthls � �Z:' /'77')JI
Z city to enter upon the above-mentioned property for lnepection purposes. ALTERORADDIOMFOH. Date Reeei tNtN
— (We)agree to nave,Indictor, and ep harmless the City of Cupertino P
agalnstllabll ks;' d rte,co and nseswhlchmaylnanywayamme AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL•
agairuts iZ en (the n gof this pe10,4/
mit
r, _ AIRHANDLINGUNIT(OVER 10,000CFM) 'CONSTRUCTION TAX
Signa of Applicant/Co actor PA Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant atom or hand le hazardous HEATING UNIT CIO 100,M0 BTU) Date Recei to
material a.defined by the Cupertino Municipal Code,Chapter 933 and the
Health and Safety Colon 25532(a)7 HEATING UNIT(OVER 100,,100 BTU) TOTAL: I
Ves o
Will the applicant future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIO) dS$UA�I�E DATE.
which cool hazardous air contaminants as defined by the Bay Area Air FDYn
Quality Management b ct7 BOILER-COMP(3HPOR 100,000 BTU)
❑Yes No IW
sy
IAaveread the haze m ,Setionsremenh5533 aChapter G95 of 90E.ER-COMM(OVER 100.800 BTU) IWAR 1 IAA9
^z the California HealthbSafely Code,outcumntly have
a tena25534.nt,
that
L
'understand that i(the building does not currently have atenanL that it is my NEW RESIDENTIAL METH. SQ.IT. y'a ♦d,LL�--�s.11
41m
o ly h cop toftherequirementswhichmustbemet CITY V
cats O anry. 'x+tY"tnilivu
t_hvImorixAfTjFnt Dale ISSUED BYq _'_
TOTAL:
OFFICE COPY