20651 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identifleatlon 7 PE SLIT NO.
Building Address:
o20651
y(b M HA,nJ �� (L-M one: p p
�I•tpt2- N N 7Z't87103 CITY OFCUPERTINO-BUILDING DIVISION ^�
Comrsator's Name: Lie.No: APPLICATION / _PERMIT L— ( (/
. SL QLp T 7 3'rM BUILDING-ELECTRICALPLUMBINC-MECIt MCAL CATEGORY CONTROL#
Archfted/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE 1:1 E] ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that lam llceneed under provisions of Chapter9(comment APPLIANCFSRESIDE FS
JOB DCRIPIION
IngwIth Srdhm7000)of DivWco 3oftheBuainessand Pro(esslons Codgand my PANELS Zn3Yk) 115t"v—
license Is In full force and effect.LicenxC m ue.x s�7Y3Y kaItt k�� 11
Date Contractor
ARCHITECTS DECLARATION 201-IMO AMPS VW
roil] I understand my phm sh U be us d as public n rd& OVER 1000 SQ.Ff.FLOOR AREA g/:Q.FT.
O
ZLicensed Professional SIGNS ELECTRAAL,
OWNER-BUILDER DECLARATION SPECIALCIRCIII
E, Ihereby affirm that l am exempt from the Contractor's License Law for the
following reason.(Section 701.5,Buslnesa and Pmfesskma Code:Any city or
F �t9+� county which requires a permit to construct,alter,Improve,dennlish,compair TEMP.METER OR IN
ranystructure prlorlo Its bssuance,also requlrestheapplicant for such permit to POWER DEVICES
Bk a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Cha erii(conameroingwithScct1on7000)ofDivi-
f,30�" sion3ofthe Business and PrefessionsCode)or that he is exempt therefromand SWIMMING IDOL ELECTRIC YALLLVNON6
O O the basis for the alleged exemption. Any violation of Section 7MLS by any OUTLE7SSWITCFIFSFl)(TUREq D
applicant for a permit subjects the applicant to a civil penalty of not room than
five F71,as ed owner of he Pr. NEW RESIDENTIAL ELECTR SQ.FT. RIES TYPECON'SIRUCTION
❑I,as owner of the property,or my employees with wages r their sok
com(Sec.7 Kwulio the work,and the structurebnot Intended oroffered for
C O slit(Sec.70K But am.and Professions Code:7he Conlranole Wcerse Law
does not apply to an owner of property who W llds or improve themon,and
$^ whodoessuchworkhlmselforthrough hisownemployees,provided that such OCC.CROUTa RFS.UNITS
Improvements am not Intended reoffered for sale.IL however,thebulli ing or TOTAL:
Improvement u sold within oneyearofcompletlory the owner-builder will have
e1iLtiurden of proving that M did not build orimprove for purpose ofsale.). QTY, PLUMBING PERMIT FGE
FLOOD LANE APN
"L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contractors to construct the proj (Sec.7044,Business and Professions Code:
M
The Contractor's Litems,Law does not apply to an owner M property who ALTER-DRAIN kVENT-WATER[FA)
Wilds or Improvera
thereon, and who contracts for such pipyets with a FEE SUMMARY
oQRt a0 (a)licensed pursuant to the Coraractorf License Law. BACK FLAW PROTECT.DEVICE
l_I f am exempt under Sec. B h P C for this reasonOUTSIDE FFI'q
Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
. Ow
WORKMAN COMPENSATION DECLARATION RECEIPT N
FO(TURFS PER TRAP SCHOOLTA% Y_ N
❑1 hereby affirm ce
that I have a rtlfkate of conxnl to self-Insure,or RECEBT'N
certificaner te ofWorkera'Comperuatfon Insurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FTE Y N
3800,Lab C.)
Policy NIaiCp I107Z[ CAPA.SYSTEhf-OVEft4(FA) RECEIT II
Com any_Sfa B UILDING DIV]SION FE ES
�CertlRedmp S b hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�-Ilserlified copy Is filed with the city inspection division.
GREASE TRAP
CERTIICATE OF Ei(EM PTION FROM WORK ER S'
FPAID
COMPENSATION INSURANCE SEW FR-SANRARY-STORM EA MET
Rhls section need not be completed If the permit to for one hundred dollars Date Recti t#
($100)nrleaa.) WATER 1iEATLAW/VENT/dECTR ENERGY FEE Y_ N_
I mrtifythat In the performance of the work for which this permit Is b aced, -
I shall one employ any person in any manner ro as eo become subject to the WATER SYSIFM/TREATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW READEM Al PWB. SQ.ET. Date Recti t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provbioss of the Labor TOTAL:
W Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE -V
W > deemed revoked. a
CONSTRUCTION LENDING AcwcY SEISMIC FEE
CL IF1'thewrk fee tthere bacerut uctiort Itisaclendln. agency Civ. .) pcAomm TOTAL: ELECTRIC FEC
7 Z ante of the work fee which this pertmtbbsued(Sec.3097,Civ.C.)
U O 1<nder•s Name PLUMBING FEE
H Lenders re
Addss Q'TY. MECHANICAL PERMIT FEE
OW Icertilythal l have readthb applicationand seaeethzttheabove Information MECHANICAL FEE
a is correct.I agree to comply with all city and county ordinance and state lawn PERhtITLSSUANCE FEES PAID:
>. N relating eobullding construction,and hereby authorize representatives ofthis
city to caterupon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,indemNfy an d keep harmiea the City of Cupertino Date Receipt#
O against liabilities,p mem rtsamd nxs whichmsyinanywayaccrus ATR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sal ty o nee of t anting of this permit.
AIR HANDLINGUMT(OVFR lo,000 CIM) CONSTRUCTION TAX
' Sigoaturcof Applicant/Contractor ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARDOUSM :RI SDISCLOSURE
Will the applicant or(uture buildi pant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Mu Ndpal Code,Chapter 9.1$and the
Health and Safety Cade SSection 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes 9 No
Will the applicant or utum Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESIU) ISSUaldx3C6.F11TE
which emit hazardous air contaminants as defined by the Bay Area Air 1�Cl/''�V�Y�
Quality Management D❑No U2District? BOILER-COMP QFIP OR 100,000 BTU)
4 Yes N q IC�.uJ
have read the haze ous materials requirements u nder Chapter 6.95 of BOILER-COMP 100,00067 U) JULI
the California I fealth k Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does nor currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
repmodbility,to notify the occupant of the requirements which most N met ^^Y�of CUpeairp
prior to issuance of a Certificate of Occupancy. ar•�
Owner or authorized agent Date ISSUEDIFf.. / 1 •`V Cy
TOTAL:
OFFICE COPY