23176 (2) APPLIC�^AJ�sNTTO FILL I/N�/INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ballot Add f��Bulldinx ro'ec �ll I/InUINA �� PJLWTNO.
3176
one: A A A
n ; ha e✓!c O(7N 2S7—g)� CITY OF CUPERTINO-BUILDING DIVISION
Coal rSnraName: / LyII5.N/n APPLICATION / PERMIT —' Z
a m C ke Ca uS U I LFi BUILDING-ELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL X
Architect/Engineer. Lic.Na
QW ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ��' {�` El El
CONTRACTOR'S DECLARATION I_�I
Ihereby di. 7000)tlamlkrn3oftheunder iressaprovisions ofChapwr esions9(wmmmc MPLIANCESRFSfDENMl JOB DFSCRII'C[ON C0612-
11
1
Ingwit 1 1fun7000)of d eff on3o(the Buslnessand['rolaslons Code,and my ��`
license]sit. fVprc{anddfel �( q PANELS
LlcenseC v 4 t LI[.X U 1 1 C�r,{a�(y�'
Date_LI.( Contractor 7UP 01 TO2DOANTS MP5 S4'oN - _—
ARCHITECTS DECLARATION
qqqq�+0 C76 I understand my pUro atoll be used as public records. M
OVER 1000 APS SQ fWR AREA $/SQ.FL
tis d`ku) Licensed Pmfesslowl SIGNSELECTRICAL
��G OWNER-BUILDER DECLARATION SPECIALCI(CUIT/MISC ER
t., , Ihereby affirm that am exempt from the Contractor's License Law for the
0 O F following reason.(Sation 7031.5,Business and Professions Code:Any city or assagat Orj
F county which requlresa permit reconstruct,alter,improve,demollsh,or repair TEMP.MLTQ4 OR POLE INST.DATE
] F�
�� any structure prior to Its Issuance,also requires the applicant for such permit to
a'N' d Elle a signed statement that he Is licensed pursuant to the provisions of the (OWER DEVICES
O u,� Contractor's License Law(Chapter9(cemmencing with Section 7000)of Divi- SWIMINUNGPOOLFT.ECIRIC
�Og sica3 ofthe Business and Professions Code)orthat he is exempttherefromand VALU/�Wa
�"•]
the bash for the alleged exemption. Any violation of Section 70315 by any TE eUTLETS-SWITCHES TURFS 0 V�/
�5 applicant fora permit subjects the applicant to a civil penalty a net more than E
e. five hundred dollars(&500). INEWRESIDFMIALELECTR SQ.FT. S[OWES - TYPECONSTRUCTION
6
r-1 1.as owner of the property,or my employees with wages as their sole
compensation,wi ldothe work andthestructure ls not Intended or offered for
5 0 sale(See.7004,Busbossand Protestor.Code:TMCordmcwea License Lsw
$$ does not applytoan owner of propertywho Wilds orimproves tMreem,and OCC.GROUP RES.UNITS
doessuchwork himself orthrough hisownempivyess,provided that s ch
Improvements arc not Intended oroffered for sale.If,however thebullding or T
Improvement is sold within oneyearofcomplatlon,the ownee bu Ilderwill have
t4g_jmden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7064,Business and Professfor.Code:
The Contractor's Llesnee Law does not apply to m owner of property who
Wilds or Improves threcon,and who contra for such project with a ALIER-DRAIN&VENT-WATER(EA)
ogatf+ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT X
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAA Y N
❑I hereby affirm that I have o certificate of consent to copy
them.,ora RECEIPT X
certificate of Workers'Compensation insurance oracertilled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800, —
RDCEPo14ya OUCa Q02. 7fs7 DING D1IV
GAS EA.SYSTEM-0VER 4(FA)
Com any CA_i BUILDING DIVISIONFEES
ertNed copylshemby lumlahed. GREASE/INDUMRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ls(fled with 1n,city InspMbn dlWalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SCORM EA.700FL. Date Recei til
(Thissectiou need not be complated If the permit isforom hundred dollars
a Bil W)or lcea.) WATER HEATER W/VENT/ELLCTR ENERGY FEE Y_ N_
1 certifying in the performance of Ne work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATT7i SYSTEM/TRFATTNG
Workers'Compensation Laws of Califomis.Date PAID
Z Z NOICE TO APPLICANT.If,after making this Certificate of Exemption,you NEN'RESIDENTIAL PLMB. AFI. Date Rectii tN
O' should become subject to the Workers'Compensation provisions of the Labor TOTAL:
F" y Code,you at forthwith comply with such prowl..or this permits hall be BUILDING
j deemad revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 FD Iherebyalfirmthatthem I,acenstrueHon lending agency forthe perform- ELECTRIC FEE
7 Z ance of the work for which this permit is Issued(See.3097,Civ.C.) TOTAL:
(.) 0 lander',Name PLUMBING FEE
LL r Lender'sAddre,s QTY. MECHANICAL PERMIT FEE
MECHANICAL FEB
Ow Icertifythatl have read thisappbationand state that theabove Information
S lscermet.I agmeto comply with all city and county ordlnancesand state laws PERMIT ISSUANCE FEES PAI D:
y relating to building construction,and hareby authorice representatives ofthls
N city to enter upon the aWvemcntlonad property for inspection purposes. ALTFRORADDIDMECH.
Z (we)agree to save,Indemnify an d harrrdem the City of Cupertino Date Reeeiptit
O aga WtbablBtlo,pdgmenb,costsand ex n whi yinanywayaccrue AIR HANDLING UNIT(TO 10,000CF1,4) SUBTOTAL:
ZIgaly teal fly sequence o(t am gd 1 permit.
f 9 AIR HANDLING UNIT(OVER 10,000 CM) CONSTRUCTION TAX
Signa cf ppll am Contractor ate IXHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA IALSDISCLOSURE
Will the a pBrant or future building eupant sore or hand le hanrdous HEATING UNIT(TO 100,000 BTU) Date Receipt
material as deftead by the Cupertino Municipal Code,Chapter 9.17,and the --- —
Ilealth and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea []No
Will the applicant or farms building occupant use equlprrcnt or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeaadous air conlandrunt,as defined by the Bay Area At,
Quality Management District? MOILER-COMP DHP OR 100,000 BTU)
Yua ❑No
have read the Fazzrdous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 75505,25533 and 25536.I B D
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to Issuance ofaCertificate of Occupancy. K.L1 JF
JAH a� i] 1O(3Xy
Owner or authonced agent Data IS5IJEDBY: a!"r/1� a7�a�LVI)
TOTAL: cal TIF a.
OFFICE COPY