20459 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project ldenrl(lution PERMITNO.
Budding Address: VJ4 20459
�1v1car. ams: 7
pV L94 Y� / 9-0rt ZS7—bS D9 CITY OF CUPERTIN0.BUILDING DIVISION _ G
C?ra/nraxame: ( I_ LIc.N : APPLICATION /PERMIT
—
`—^^�m� A!4 KXAk S� D<Y BIl)LDING-ELECTRICA4PLUMBINC-MECFIAMCAL CATEGORY CONTROL#
Archltetl/Engineer: 7U LIc,No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address )273 �I� 1. l .[.�... $ PERMITISSUANCE ® ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyslfUmthat l amIcensed under provisions of Chapter 9(commenc APPLIANCMRESIDENTIAL TOB DESCRIPTION
ingwith Setlon 7000)o(DiA.1on3ofthe Buslneeaand PmfeWon,Codgand my
Ilanss is In full rad affect. PANQS
Dine Cl Lmur d1�
DateyfL-eL�CHITECr -
ARCHITECTS DECLARATION IOW
Q rrr7��� I understand my plain shall be used u public remnlw O 1 li �.FT.FLOOR ARG f .FI'.
E'2: Licensed Professional SIGN L 'TRIC
<<�6 OWNER-BUILDER DECLARATION `SPEqjCIL /
21. E �ercby affirm that l am exempt from the Contractor's License Law for th
Q following reason,(Se tion 70313,Business and Professions Cade:Any city o
0,"F' county which requires a permit to construct,alter,Improve,demaibh,or repair PM O ST.
say structure prierto its Leads nee,also requires the applicant for such permit m
N'a y file a signed statement that he Is Ieensed pursuant to the provisions of the vp CES
Oµ Contractors License Law(Chapter 9(commencing with Section 7WD)of Divi- '
H OS Yon3 of the Bul,,,,ndProfessions Code)or that he b exempt therelromand MI POOL C VALUATION
the Wain for the alleged exemption. Any violation of Section 70715 by any ETSSWITCHaWI ES D
QO
applicant nt for a permit subjects the applicant to a civil penalty of nmothan D
flue 1,as
ownerdollar
(,M, NEW RESIDENTIAL ELECTR SQFI'. 6IpWFS TYPECONSTRUCTION
I,as owner of the property,or my employes with wags as Their door
sale compen&C.
will Busio the ness
and rk,Pr and the slmde:Thure Contractorot or License d for
Law
q doe nota ply to ainower of property
who
or impmofs thendslaw
�$
who
odoas such torn awnero(prough who Wildsoown yees,pvesthercaryuch OCC.GROUP RM UNITS
whodoesents am work Mmsededorwghh farsal .If,ho however,
dthat he ild ing or
improvements areestlntcndneoroffeco pletioe.If, reamer-p deer ill have TOTAL:
Improvementbwldwithln oneyearolcompldlon,Iheowner-bu0derwlllhave '
th,,kurdeo of proving that he did eat build urimpreve for purpmedsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contnctas to construct the project(Sec.7044,Business and Professions Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve,thereon,and who contracts for such pWjec,with a
copajj�Taiorts)Bcenued pursuant to the Contntot'a Llanss Law. FEE SUMMARY
I—I 1 am exempt under Sec B A P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
' Owner Date RECEIT M
WORK MAN COMPENSATION DECGRATION FDnURES PER TRAP SCHOOL TAX Y N
QI hereby affirm That I have o Ine-ate of consent m opyth rao ora RECEIPT#
artlflateofWarken'Compevatlon lruunnce ore certlford copythereof(Bac.
3800,Isis CJ GAS G.SYSTEM-I INCA OUTLETS PARK FEE Y N
RECE
CO an
/*YY 4l74 Z3V DING IV
GAS G.SYSTCM-OVER d(G)
Co�mpanv E _�fu Y1D BUILDINCDIVISION FEES
911'anrtlB.�v copybhereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCFIECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SLWERGNITARYSTORM G.2WFT. Date Rmi tic
(This session need est be complied If the permit b Ionone hundred dollars
(f100)orfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that In any personhe i an tmannerhe so as to b corn permit le issued, —
I shall not empty any person In any runner at as to become subject to the WATER SYSTEM/TRGTIN'G
Worken'Compensatlon Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFL Date Remi t#
Z O NOIICETO APPLICANT.If,after making thin Certificate of Exemption,you
Hshould become sub)ed to the WorkerCompensation provleloru ofthe Labor TOTAL:
W Code,you=at forthwith comply with such provisions orchis permit shall be
W j deemed revoked. BUILDING FEE 7-
'P49
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE 377
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
Z and of the work for which this permit is bsued(Sec.3097,Civ.CO TOTAL:
o Q Iendxe.Name PLUMBING FEE
LL I— Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtlfythallluvereadthisapplallonendstalelhattheabovelnformatlon _
a Iscorset.I agree to comply with al city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
HZ city to enter upon the above-mamtkmed property for Wpectlon purpose. ALTER ORADD'R7 METH. Date Recel IN
V — (We)agree to save,Indemnify an d kap harmless the City of Cu pedlno P
against llabllltles,judgments,comi.ad expenses which may In say wayaame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid City Incondtryence of the granting of this permit.
�'ra� </2� AIR HANDLWCUNIT(OVER IQWOCEM) CONSTRUCTION TAX
SlgrtlhTre of A)Ypliant/Contractor /Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldlogoctupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel tin
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
I lealth and Safety Code Section 75537(a)I HEATING UNIT(OVER 100,OW BTU) TOTAL: PL2 N1
Yea No
Will theappliant or uture building occupant use equipment or devices VWIHATION FAN(SINGLE RFSID) ISS ATE
which emit hazardous air contaminant...defined by the Bay Area Air nV
Quality Management Disvlss7 DDILFR-COMP OHPOR 100,000 BTU) ��1afr rs �rsno
4 Ya I—I No r G `99
Tho readthehawr�iwsmmcrialsrequimmentsunder Chapter6.95of ER-COMP(OVER 100,000 BTU)
the Calif=Health k Safety Code,Setlom 75505,75533 and 25534.1 CU
understand that lithe building does not currently have a tenant,that It b my NEW RESIDENTIAL MECIL SQ.FY IG1�V ..{ O�wass/d
responsibility to ratify the occupant of the requirements which must be met 111 II Waruw
prior to Issuance ofa Certificate of Occupanry.
Owner or authorized agent Date
TOTAL: ISSUED BY: 41tilV'L ,
OFFICE COPY