21746 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO,
B°Ildie.g Addren: 21746
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nets amu: one.
A
CITY OF CUPERTINO-BUILDING DIVISION
. • apt Na :
` APPLICATION'/ PERMIT
f ~ BUILDINGF3.F MCALPLUMBINC-ME)CHANTCAL CATEGORY CONTROL 0
L f QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION FF
I hereby affirm'MtlambcenadunderprovWs sof Chapter9(mmmmc APPIIANCFSRESIDENTIAL JOB DESCREMON
ingwRh Secthm7000)o(Dlviaion3 oftheguslnenand Pro(esionsCede,and my
R¢nx Is in!uv fprte andefied. �r ^I/F PANF'IS
LI¢nx Ctse Ll
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMTS
�% l un irromed my plan shag be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
wO
�do�
Licensed Profesbnal SIGNSELFCTRICAL LIIII-S
OWNER-BUILDER DECLARATION `� .'
Ian Fn SPECIALCIRCUIT/MDC //
7 Therebyaffirm tMtlaro exempt from the Cnntractora License Lwfor the ('r• 14-
O 'q� following rcuon.(Seniors 9015,Buslnes and Pmfealona Code:Any city or ( 'r'j 14
-
TEMP county which requiresa permit ItxgIm rove,demoW 1 TIIdP.METLRORPOLEINST. Zs
K aI tYR eta P demolish,
�az��.c anystructuresigned
nurc prtemenits lsmaneq also sed pursuantthc t the provisions
ofpermit e POWER DEVICES
c file a shed easement that he ls licensed pursuant to the proWlom o! the
Oa actoe.Llcl (Ct9with 9000fD
mn )oivl-
Ofn CmtraSWfASMING POOL ELECTRIC
Hl,imn3of the Budnmand Proleslona Codr)orthat helsemm thertfromand � ///'••��,VALUATION
5 the bast for the alleged exemption. Any violation of Sections 7MIS by any OUTLETSSMICHESFD(TURFS /�1
applicant for a permit subjntsthe applicant to a civil penalty d n¢moretbn /
r. five hundred dollars(5500). NEW RESIDENTIAL ELECTR
I,as owner of the property, SQI'T. STORIES M'EClINSTRUC]ION'
�j ❑ p prrty,or my rmture is with as there.ale _
k7Q, compensation,BuwilldosMwProfesionorl,,and the s Code:The Cofot actornded or License
eLaw -
S ❑ d for
dole(Sec 9011,to Businessand Professions Code:The or improves
hereon Taw
$ whoddoes ot applytoanowner ofpropertywho buildaorlmprovnthereaRand
uch
�S^ wM1odorsanchworkM1lmseVorthrmgh hbownemployee,provldedtM1at such OCG GROUP RFS.UNITS
improvement art not intended orof(ered forsale.If,however,thebuildingor TOTAL:
improvement tsold within oneyearofcompletlon,the owner-WilderwW have
the—old,of proving that he did not build or Improve for purpose ofsle.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
L as owner of the property,am exclusively contractingPo with licensed PERMITISSUANCE
cosThe Co on to mmtroct L project(Sec.app) to nes and of property
Code:
The Contractor's Licensehelaw don not apply cis an owner a(property who
Wild.t Improve thereon, and who mnmam f¢such ptojens with a ALTER-DRAIN kVFM-WATFIt(FA)
m ltnnOm e licensed pursuant to the Contractor's License Law. FEE SUMMARY
L�I am exempt under Sec. B A P C for this reason BACK FLAW PROTECT.DEVICE
DRAINSFLC(R,ROOF,AREA,COND. a SANRARY Y_ N_
Owner Date RFCm•F R
WORKMAN COMPENSATION DECLARATION FIX.IURFS-I'FR.TRAP SCHOOLTAX Y_ N
111 hereby firm that I have•certificate of consent to self-insure,ora RFCF1Pf X
3800,labb CJ
aertlflao(Work<ri Compematimnlnuranceora adlfled copytherot(Sm. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N
RECEPall Y - GAS EA.SYSTEM-OVER BEM DING DIN
Cam ams /T — / BUILDING DI VISION FEES
❑Certified ropy t hereby fuml.h GREASE/INDUSTRL WASE INTERCEPTOR PLANCHECK FEE
h n�Certifled ropy t(fled with the city Wpection dlvlslon.
'�+ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SAMTARY-STORM EA.NOFT. Date ReC i ted
(I'hlsxnlan need not M completed the permit ls for one hundred dollars
510D)or lens.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I certify that In the performance o(the work forwhich this permit t Issued,
1 shall no employ any person In any manner n as to become subject to the WATERSYSEEM/TREATING
Workeni Compensation Laws of California.Date PAID
-
z Z NOplicant TICE TO APPLICANT:If,a fter making this Certificate of Exemption,you NElY RESIDENTIAL PCMB. SQFI'. Date RCCCI t#
2 should become subject to the Workers'Compensation pmv[tlona of the Labor TOTAL:
W >Ln Coda you=at forthwith comply with such provisions orthla permit shall be BUILDING FEE
deemed revolu.•d. 7
CONSTRUCTION LENDING AGENCY SEISMIC FEE
(Z IhembyafRrm that there is a construction lendlegagenq•for the perform ELECTRIC FEE
7 Z a n¢oftheworklo,whichthispermi ls temed6ec3097,CIv.CJ TOTAL:
02 Lenders Name f PLUMBING FEE
IL I= lenders Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cemfythe l have madthtappll tion and saethatthe aboveteformation
4 ismrrect.lagrectocomply withal)city and countyordinancoandrotelaw. PERMIT ISSUANCE FEES n
} relatingtobuildinSmntrunion,andhrmbyauthor empmwntativnofthls
city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMFCH.
Z inspection Date Reeei tis
(We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino P
V against ltbilitfa,judgment,ones and expense which may In any way... AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this pe it
AIR xnNDUNc uNrr(DYER IB,000cnt) CONSTRUCTION TAX
C CO T �CTION TAX PAID:
Signature otA plHAZA ontractor to D(HAUS'T}IOOD(W/DOLT) Z / ( G6f--6
HAZARDOUS M T occupa DISCLOS RE '
tWill l.the appliadbythutunbuilding oaupantstonorhandle 9.h..dous HEATING UNIT(TO1W,000 BTU) Date Recel tis
rsrtertlas Sifety ode SCupertino Municipal Cade,Chaplet 9.12,and the
I lealth and Safely Cade Section 75537(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. r F No
Willemu appllantorruture building oaupandby theequipmentArea devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit h gcmcrus air contaminants a defined by the Bay Area Air {��
Quniity Managernnt Dislrfct2 BOILER-COMP(,3FR'GR 100,000 BTU/ F�
Yes ❑No
have read the hazardous materials requirements under Chapter 6.95 of BOILFR-COMP(OVER 100,000 BTU) 1 FEB
'1 � �Q[I.7�
the California Health k Safety Code,Sections 75505,2593 and 75530.1 t7
understand that it the building does one currently have a tenant,that it la my NEW R®DFNITALMECH. SQFT. -
respomibility to unify the oaupant of the requiri which most be met �q�,� u
prior to issue ace of a Certificate of Ocmpa nry. •eat (4 Min^
�, � � � *. -v
Pvner or oath teed agrnt D*. TOTAL
ISSUED BY:V
TOTAL:
OFFICE COPY