20261 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO. O
Building Address: 2
261
76 S3 1055�� /^.
I Ln,merB dmC: Onl.
A
Y kfayZIF—� CITY OF CUPERTINO-BUILDING DIVISION ��v �n
Connectors m!: ,L./ Lic.Nc: APPLICATION / PERMIT
mss^ m BUILDINC-ELBCTIUCALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie.N°: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu: a. /1 // iC PERMIT ISSUANCE Z.a)
LICENSED CO ACTOR'S DCCIARATION
Ihereby affirmthit l am licensed under provisions of Chapter9(commnc- APPLIAN ESSRFSTDENTIA JOB DESC 'TION
ingwlth Slclfen7000)of Divislon3 ofthe Buslnemand Professions Code,and my I
liana 1.1.Fell to.and e-A Ss-9 PANELS K�
Dal
Claes Lk.X ( �� \\1 .\ e
DmeqP_Contractor_ �a.9•Vf��I1'r�`
ARCHITECPS DECLARATION OVER
ANNS
�Z (understand m7 plamshaube used As public records OVER 1000 S SQ.pit.FLOOR AREA E/:Q.FT.
t�CO
L�j LlcenudPMesslonal SIGNS ELEC L
¢' OWNER-BUILDER DECLARATION SPECIALCIRCUI MLSC
so., Z Ihereby affirm that l am exempt from the Contractor's License Law for the
FO��a 7 F q following reason.(Section 70315,Business and Professions Code:Any city or TFMP.ME[FR county which requires a permit tocoratmct,alter,improve,demollsh,or repair L
any structure priorto its issuance,aisorequlresthe applicant for such permit to DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Contnaorb License Law(Chapter 9(commencing with Section 7000)of Divi- N E
sion 3 ofthe Business and Pr°fessbnCode)or that he is exempt therefmmand ^ 1fALUATION
yl the basis for the alleged exemption. Any violation of Section 7011.5 by any O FIXTIIRFS
appileant for a permit.ubjed.the applicant to a civil penalty of not more than 1 .J
$ five hundred dollars($500). NEW DENIAL ELFOTR SQ.FT, STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for
Oole(Sec.9064,Business and Professions Code:The Contractors License Law
r$ does not apply to an owner of property who builds or improves thereon,and
3^ provided that such OCC.GROUP RFS.UNITS
lmpmve such intenorihroffemdfwle.Itoyen,p -
Improvementiarenotintendedorrofc forsale.ILhowever, ilder ilI have TOTAL:
Improvement bsold withinoneyearo(compictkn,theowner-bulloerwlll have
t4q-tairden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec 7064,Business and Profenioru Code: CV
The Contractors Llmnse law don no apply to an owner of property who ALTER-DRAIN kVENT-WATER ffNN
builds or improves thereon,and who contracts for such ptojects with a FEE SUMMARY
coJJBdTIactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI1 am exempt under Sec. B k P C for this reason
D.1TSIDF FEES
DRAINS FLOOR,ROOF,AREA, NI SANITARY Y N
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N
hereby affirm that I have a certificate of consent to self-Insure,or auk FIX'IUAFS PER TRAP L RECEIPT#
am lateafWorkeri Compensation lmurmoo or a certified copythereof(Sec. GAS EA.SYSTEM.]INGI OUTLETS PARK FEE Y N
3800,lab C.) , I� / .i�' RECEIPT
P°Ikyp GAS EA.SYSTEMOVER 4(EA) BUILDING DIVISI ON FE ES
Com�art Cdlfied copy ledwththeed.2 GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CcrtlRd copy V(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(This section need not be complded lithe permit k for one hundred dollars
(EI00)or less.) WATpi HEATER W/VENT./FlFLTR ENERGYFEE Y_ N_
I certify that in the performance of the work forwhich this perrrdt Is lasued,
1 shall not employ any person In any manner so An to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Z Applicant NEW RESIDENUAL('LMB. SQ.FT.
2Date Recei t#
:NOTICE TO APPLICANT:Ra
,after making this Certificate of Exemption,you
should become subject to the Workers'Compemat lees provisions of the Labor TOTAL:
f2 Code,you=at forthwith comply,with such provisions or this permit shall be BUILDING
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby afRmt that there is a construction Lending agency for the perform- ELECTRIC FEE
7 Z ante of the work for which this permit is lamed(&c.3097,Civ.C.) TOTAL: e(!Z)
02 Lender.Name PLUMBING FEE
U. H lender',Address QTY. MECHANICAL PERMIT FEE MECHANICAL II
O W 1 omilythat l have read thisappilationand statethat theabove information
a It correct.I agree to comply with all cityand county ordinances and state laws PERMIT LGSD
UANCE FEES PAI
relating to building construction,and hereby authodm reprexntatives mf thh
N ALTER OR ADD TO MECH.
[— dry to agree
to the,indA mnify a ed property inspectionitpurposes.
_ ZDate Receipt#
(We)agree to save,Indemnify and keep harmless the City of Cu accrue V against liabilities,jitdgminb,coxaand expenses which may in any way acauA HANDLING UNIT(17010,000 CFM)accrue SUBTOTAL:
against said City in conscyuence of the Binmting of this permit. CONSTRUCTION TAX
AIA IiANDLINC UNIT(OVER 10,000 CFM)
Signature of AppBant/Contractor Data EXHAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplica est or future building occupant store or hand le hazardous HEATING UNIT(TO IDg000 BTU) Date Recd t#
malarial m defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
health and Safely Code Sedion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 1
F1 yes No
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) LSSL�A[CI�CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air L_P`9a
I Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
_YnNo
have ad titch za�ou,cote a req lmm nsunder Chap er 6.95 of BORER-COMP OVER 10J,000 BTU) t1nY
the California Hmlth k Safety Code,Sediom 25505,25533 and 25.5X. 1 t
understand that ifthe building d es not currently have a tenant,that It is my NEW RFS(DENIAL MECH. SQ.FT.
rnpomyto ibllitdyt tof th is which must be met city pf P11"Ortinn'
prior to tmua fa if
re rauthorP agent Dace TOTISSUIED BY:
AL:
OFFICE COPY