20438 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru act Identification - PERMIT NO.
Building Aaarea.: / �,�. 20438
AVE-. C(� rdc�
antpe: p.� /a one:
t.+
am' .{J 2.rZ—?J,9/ CITYOFCUPERTINO-BUILDING DIVISION
C�nctar'sN me: LIC.N. APPLICATION /PERMIT �_ G
u12 C' BUILDING-ELF CATEGORY CONTROL M
Architect/linglneer. Lk.No:
_ QTY ELECTRIC PERMFr FEE BUILDING PERMIT INFO
Atldresc PERMITISSUANCE -C1 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrm that[am licensed under provisions ofChapter9(comment, APPLIANCFS-RESIDENTIA JOB DESCRIPTIONingwllh Section7000)of Division3oftbe Busira•sand ProfeWonsCocie,and my
license is In full force and effect. PANELS
License Chss ,R ic.
L
Date Gic.# 1
ARCHITECTS DECLARATION 201-1000 AM
p CO Iunderaland my plane shallbe used as pubOcrccords. OVERIOOOAMPS SQ.Fr'.FLODR AREA E/SQ.FT. -
k I(� Licensed Professional SIGNSELECTRICAL T
�< - OWNER-BUILDER DECLARATION 5PFAIALCIRC /M15C
o 5 I hereby afarm that l am exempt fromthe Contractor's License law for the
following moon.(Section 70314,Business and Professions Code:Any city or TEMP.MEM LC
r„E ceunlywhich requlresa permit W eenslrect,alter,Improve,demoWh,orrepair
4q anystmc mprlontoiUbwance,aborequirc•lheappBrantforsuchpe ito (OWER DEVICES 1
6 file a eiSred statement that he te licensed pursuant to the provisions of the
Contractor'.License law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING IDOL C VALUATION
SOS0
den 3ofthe Burmese and Pnefrsslons Code)or that he bexempt therefromand _the bases for the alleged exemption. Any violation of Section 70314 by any OUTLETSSWHS
CHEFIES
Applicant fora permit subjects the applicant to a civil penalty of nut more than
flue hundred- es(the pr. SQ}7, SIOEES TYPECON5IRUCTION
A NEW RESIDENTIAL ELECTR
�n I,as owner 11 the property,or my employees with wage as thele cele
ccm�en..B..,wllldothework and the structure b not Intended or offered for
sale(Sec.70K H..ir... d Prof.iors Cade:The Co.t d.e.Li..Law
r3 does not apply to an FS.owner of property who builds or Improves thereon and OCC.GROUP RUNITS
who doe•wch work himselforthmugh his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within oneyearo(completion,the owner-bullderwW have
tl,EILII nden of proving that he did net build or Improve for purpose ofsale.). QTY, - PLUMBING PERMIT FEE FTAODZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to co.truer the project(See 7014,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
build,or Improves thereen,and who contorts for such p(njects with a
cgp(R�dents)hmnad pumount to the Contactor)License Law. FEE SUMMARY
LI[am exempt under Sec. B k P C for this reason BACK FLAW PROTECT.DEVICEOUTSI DF FEES
_ DRAINS FLOOR ROOF,ARI�COND. SANITARY Y_ N_
RECEIPT
T- WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIi00L TAX Y N
'�I hereby affirm that I have a certiaam of consent to self-Insure,ora RECEIVE M
--.nl0mteofWorken'CompevatI.I.ranmoraanlfkd wpythemof(Sec. GAS EA SYSfpld-I WC4 OU1LFrS PARK FEE Y N
3800,Lab C.)
Policy g RECEITT p
CAS EA.SYSTEM-OVER 4(G3)
CO any - BUILDING DIVISION FOES
�Certlflyd copy furnished. GREASE/INDUS'TRL WASTE INTERCEPTOR PLANCHECK FEE
Cenlfled copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' - CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7WF1'. Date RCCCi [#
Rhes seelon need not be completed lithe permit b forone hundred dollars
(9100)orless.) WATER HEATER W/VENT/ELEM ENERGY FEE ' Y N
I certify that o the petaxo in any m work so As to b this penult slowed, —
I.half not employ any peaon In any manner at es to barons subject to the WATER SYSTEM/TREATING
Workea'Compenutlon laws o(GII(omb.Data PAID
Z Z Applicant NEW RESTDRNTIAL PLMB._� .Fr. Date Ret i t#
Z O NOFICE TO APPLICANT:If,after nuking this Comfiest•of Exemption,you
should become wbjact to the Workers'Compensation provisions of the Labor TOTAL:
fA Code,you must forthwith comply with such provisions or this permit shall kebe
N
LU j deemed revod. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
G FEE
a C I hereby affirm that there b aconstructlon lendingagenry(orthe perform- ELECTRIC FEE a
Z anceofthe workforwhich/his permit b timed(Sec.3097,Clv.C.) TOTAL:
•V2 Render'.Nana PLUMBING FEE
LL F Lender's Addres. - QTY. MECHANICAL PER FEC' MECHANICAL FEE
OW Icertifythetlhaveread thb•pplicatbnand mtethattheabove information
EL bomeret.I agree to complywith a0 city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
Y N relating to building construction,and hereby authorize representatives ofthb
F U) city to enter upon the abovo-mentloned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save indemnify an d keep harM m the City of Cu penin t Date' Rec i t#
V againstlbbiilties,judgerese ,masa expenses whlchmaylnanyway... AIR HANDLING UNIT(170 10,000 ChM) SUBTOTAL:
agalysiyld Ci Inns sequence he gra rating o(thls permit.
acl AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of gnat/C r or Date E)GIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD01US MATERIALS DISCLOSURE
Will the Applicant or future building oesupant store or handle hazardous HEATING UNIT DO 100,000 BTU) Date R.- I#
materbl as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
II❑ Yea
Safety Cade`Section7S537(a)7 I EATING UNIT(OVER 100,"BM TOTAL:
No
Will the applicant or❑futum building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 1—N p OSSUUAN DATE
whichemA hazamous air contaminants as defined bythe Bay Area Air \ �J
Quality Management District? BOILER-COMP OTB'OR 100,DU BTU)
❑Yen ❑No
(h ave read the hazardous malenala requlremenle underClupler 6.95 of BOILER-COMP(OVER 300,000 BTU) 1:1 ,)'�� y 13�L7
the California Health A Safety Code,Sections 25505,75533 and 15534.1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to ndlfy theoccopant of the requirements which mu at be met IhT of LIIBgr,•µ{IT�i CIIBQfIl00
prior to Issuance of a Certificate ofOccupancy. anq
Ownerm authorized agent Date
TOTAL: ISSUED BY: ��11V
OFFICE COPY