19777 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Build Ing Address: - a$ (�1'�
aarki
hon I aAA .
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r ams: CITY OF CUPERTINO-BUILDING DIVISION C O
.Name° 4,y_ Li APPLICATION I PERMIT
t,EN
v BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL p
Architect/ g( er, Lic.No:
} Qri'`' ELECTRIC PERMIT " .',FEE tBUILPiNG PERMIT INFO
Address: SI PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm
— that lam licensed erprovisions of Chapter 9(mmmenaAPPLIANCES-RESIDENTIAL-L ,
JOB DSCRI'TON
Ingwlth5aon7000)ofDlvsion3oftheBusnsa.dProfeslonsCoae,and my
fcensel-1effect •
PANELS ^
Lice C Lk.p fir'-(,
Date Contractor — 'n Il
AACHITECT1 DECLARAT ON 301-1000 AMPS
Z I understand my pkra shall be used as public records. OVER1000AMPS - SQ.FF.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
Gin c� OWNER-BUILDER DECLARATION-"
' SPECIAL CIRCUIT/MISC
Z t, 4 I hereby affirmthat l am exempt Contractors License Law for the
pp following reason.(Section 71315,Business and Professions Code:Any city or
ir TEMP.METIR ORPOLE I
�4
countywhicpriorrequwsspemnite,to rorotmuices theact,alter, provgaemolth,armit to
aryatsigned priorwitshe In atoned pursuant to the
rovisior hpermite POWERDEVICES
O fits a signed statement that M t licensed pursuant to the provieloru of the
Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
� � sion3ofthe Business and Profemiom Code)orthat he texempt therefmmand SWIMMING POOL EL ^ VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any U
00 applicant fora permit subjects the applicant to a civil penalty of net mare than OUTL SW[TCHESH IS
five hundred dollars($SfX). NEW R ENTIAL E&TR .Ff. STORIES TYPE CONSTRUCTION
I]I,as owner of the property,or my employees with wages as their sok
Z¢ compensation,wW do the work and the structure is not intended or offered for
O sale(Sec.7094,Business and P ofi satire Code:The Contractor's Limrue law
does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered forests.If,however thebulldingor
Improvement usold withinoneyearolcompletioktheowner-builderwill have .
tl)g_�rurden of provmgthat he did not bund or improve for purpose ofsale.). S2TY, :. _,. '' B1NG]!i'RMIT FEE
u 1,as owner of the property,am exclusively contncting with Ilrensed PI.00D ZONP- APN
contractors to construct the project(Sec.7044,Businessand Profmslona Code: PERMIT ISSUANCE
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
builds or Improves thereon, and who contracts for such ptojects with a
,11t[aetor(a)licensed pursuant to the Contractor's Llcenas Law. FEB SUMMARY.
u 1 am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
Owns FEES
DRAINS FLOOR ROOF,AREA,MNE:i. SAMTARY Y NOUTSID�
Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIgnURES PER TRAP SC1{OOL TAX Y_ N_
I hereby affirm that I have a l rti of consent to ripythemof ora REC=#
cemtirate o(Workera'Comperuatlonlruurance are certified ropythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
k
Com anv "—I�TY CI�It'=—I I��CI�f P 1 GAS EA.SYSTEM-OVER 4(EA) BUILDINGDING DI DIVISION FEESkilled cop thereby furnllhed. --� GREASE/INDUSFRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy t filed with the n4,impeetlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
SEWFILSANTIAgY-STORM FA 3ooFl. Date Recei t#
(IMasection need fiat be completed](the permit tlorone hundred dollars
($1 Imftifyte,) in WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify that employ
an person in annce y
th unnerwork so as to beco permitjest to theed, —
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Woplican Compensation lawn o(GII(omia.Date PAID
0 Z Applicant NEW RESIDENTIAL ELMS. SQ.ET. Date Recei t#
Z O NOTICE co esubje ttothe after rs'Comal,firpe sationCertiflprwiscate of Exem)rt eLabu
shouldbecomesubjectto the ply with
Compensation provtiomomits Labor TOTAL:
LUN Cecereduvolmd,at forthwith comply with euchprovtbru orthls permit shallbe BUILDING E
� deemed revoked,
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a mnstrocron lending agency fonts perform- ELECTRIC FEE
Oarm of the work for which this permit t Issued(Bice.3097,Civ.C.) TOTAL
O _ Lenders Name PLUMBING FEE
14, E Lenders Address QTY, :MECHANICAL PERMIT FEE . MECHANICAL FEE
Irled
O W I rertilythatl have read thtapplicationand slatethattheaboveinlornution
1 Is correct.I agree to complywith all cityand county ordinances andstatelawa PERMUISSUANCE ' FEE-PAID
:
} W relating to building construction,and hereby authorize representativeso(this -
(_ Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTOMECH. - Date ROCei
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Pt#
against llabllitles,J.rdgment,emtsand expenses which may In anywayamrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
aga' t d Clty In consryuei e filial ing of tl Is pe ¢ -
AIR HANDLING UMT(OVER 10,000CFM) CONSTRUCTION TAX
tire of Applicant/Contracor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA3ARDOUSMATERIA 1 SCLOSU E
Will the applicant or future building occupa store or ha hazardous HEATTNG UMT(T0100,000 OTU) ,� Dafe Recei t#
material as defined by the pertino Mu niclpal Code,Chapter 9.l Z and the ,eye
Health and Safety Code dion25533(a)9 HEATING UNIT(OVER 100,000 BTU) TOTAL: l_C
❑Yea Na
Will the applicant or,future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Area Air
Quality Management Dist' 7 BOILER-COMP(3HI'OR 100,000 BTU)
4Yca No
have read the taxa ouematcriatrequlrementsun der Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI)
the California Health&Safety Code,Sections 75505,25533 and 25534.1
understand that If the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. 5Q.FF.
maporoibnity to notify the occupant of the requirements which must be met
pr' r issuance oma Certlfical of anry
uthoriud agent ate �u�
TOTAL: ,� ISSUED BY:
OFFICE COPY