20094 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build Protect IdentificationPERMIT NO.
Bonging Add reaf�0094
O^' A
ZS /Pe G 1474
me: one: - A
•� D,- A s CITY OPCUPERTINO-BUILDING DIVISION
Conga or'aNa Lie.No: APPLICATION / PERMITIt
Architect/En .. - BLALDING-ELECTRICALMUMBING-MECIIANICAL CATEGORY CONTROL
LicNo:
gineer. .No
QTY ELECTRICPERMIT f .FEE ,oBUILDINCPERMIT,INPOi, -
Address: - PERMITISSUANCE } , ,a ❑
LICENSED CONTRACTOR'S DECLARATION J9 E
Thereby offlrm that l am licensed under provisions of Chaptcr9(commenc APPLIANCESRESIDENTIAL JOB DI-SCIPT
RION
on -
ingwith Secti7000)of Division 3ofthe BusinemandTrofessionsCode,and my
license is In full force and affect. PANELS -
U...Cla® Lica �• ,
Date Contranor
ARCHITECT'S DECLARATION - 201-1000AMPS
02 I understand my plans shall be used'as public records. OVERIOOOAMPS 1 SQ.FT.FLOORAREA 3/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL ;
< OWNER-BUILDER DECLARATION
rn SPCCAL CIRC MISG
2h dherebyafOrmthatlam exempt from the Contractor's License Law for the
o foilowing reason.(Semon 70315,Busineu and Profeasbns Code:Any city or
OZF,� coon whlchrc Iresa rmittoconstmct,alter, TEMP.METER OR INS
�� �:
county qu pe prove,dem011eh,orrcpalr
.a anystmaumpeortoltslswance,abarequbeslheappiicentforsuchperMtto POWER DEW
� c. file a signed statement that he Is licensed pursuant to the provisions Ot.the
Ou, Contractor's LlcenseLow(Chapter9(cormmencing with Section 7000)ofDivi.
30� slon3ofthe Busincmand Profemions Code)orthathetsexem thercfromantl MING L ECCRI VALUATIONiN�
the basis for the alleged exemption. Any elolatlonof Semon 70315 by any PTS XTURES ^, CY
3 .aPpReant fora permit subjects the applicant to a civil penalty of not more tion 00
c. five hundred dollars eiSON.
Sn ❑I as owner of the property,oremployees with ova ee as their that, 1' 7R SQ'r' STORIES 'IYI'E CONSTRUCTION
• P perty, my ean
compensation;will do the work and the structure la not intended or offered for
Osale(Set 7014,Business and Professions Code:The Contractor's License Law
�5$ docs not apply to an owner of property who builds or improves therecn,and OCC GROIII' RES.UNITS
who does such work himself orthentgh hisown employees,provided that such
improvements arc not intended oroffered forests.If,however,the building or, TOTAL:
improvement used withineneyearofcompletioNthe owner-bu0derwill have
If a L men of proving that he did not build or Improve for purpose o(sakJ. QTY, PLUMBING PERMIT ,,,FEE' FIOODZONR APtyN
Luf as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:The Contractor's Licence Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
hu Ods thereon,
or Improves and who contracts for such'p -
pRch, with a IFEEISUMMARY' "
orfs)licensed pursuant to the Contractor's Limnos Law. BACK FLOW PROTECT.DEVICE
erupt un er SeeB k P C for this rcuon
DRAINS FLOOR;ROOF,AREA,COND. SANITARY Y N_
nen Date REC=M `
WOR gNAN CO SATION DECLARATION FTI('TURESPER'TRAP SCIi00L TAX Y_ N
hereby affirm that 1 ha e a certlRate of concent to sdf-Insure,ar a RECEIPT N
certl(icate ofWorkeraCmepevatlon lrsuranceora mrtifird copy thereof(Sm. GAS FA.SYSTEM-1 INC.40[fILETS PARK FEE Y N
3800,Lab C.) ,
Poon a - GAS EA.SYSTEM-OVER RFO[BPTp
Cam any BUILDING O I VIS ION FE BS
[�Certmed copy b hereby furnished' GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Ceitilled copy lafiled'Mth the city impaction division. ,
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP -h
(This sPAIDH-4-10 ,r'
COMPENSATIONINSURANCE SEWER-SANDARY-yTORM EA 200f7, .Date Recei f# Ia
'.
mlon need not be compltd lith
eee permit V(orooe hundred dollars
I(4100B.H..) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I unify that In the performance of the work for which this permit Is lamed,
'71 hall not employ any person In any manner ce.to become who&to the wATERSYSTEM/TRFAT(NG
worker;Compensation Laws of California. Date , PAID
O Z Applicant NEW RESIDENTIAL P A B. Q.FT, Date Recei of
Z 0 NOTICE TO APPLICANT.If,after making t Ms Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
cc I. N Code,you moat forthwith comply with such proWiOns or this permit shall be
LU D deemed revoked. - - - BUI
- aC1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hembyaffimthat there is a construction lending agency for the perform, TOTAL: ELECTRIC FEE I
ance of the work for which this permit is Issued(Sec.3097,Civ.C,)
V,Q Lender's Name PLUMBING FEE
LL h ' Lenaerb Address Qn. . MECHANICAL'PERMIT FEE MECHANICAL-PEE
OW Icertifythat i have read thisapplicatlonand statethatthe above information
CL Iscorren.I agereto comply with all city and county ordinances and Gate laws PERMUISSUANCE FEES PAID:
} relatingtobulldingconstmnion,and herebyauthorizempresentativesofthei _
F- U)
city to enter upon the above-mentioned property for Inspection purposes, ALTFRORADDTOMECH. DateRCCCi t#
V — (We)agree to save,Indemnify an d keep haredesathe City of Cupertino p
against ilalellaes,judgments,ost.and expenses which may In anywayaceme AIRFANDUNG UNTT(TO IQOOOCFM) SUBTOTAL:
ago Wt said City In consequence of the granting of thio permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigwtureof Applicant/Contranor Date FJ(HAUS'THOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappliant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ,Reeel f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I1ealth and Safety Cede Sedion 25532 W? I MATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes r]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINCLE RFSID) ONCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air -
Quality Management District? BOILU-COMPC311POR 100.0(0 BTU) APR /9
M Yes No r7 P p O
have read the baza Ous materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) J lySlJ
the California I Ialth A Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have a tenant,that it is my NEWRFSIDPNTIALMECIL SQ.Ff. CRY-OcA j
res to notify the occupant of a requiremenowhlch must be met -�-' �B.QT/ja.rrr. i
or to lass nu O(a Certificate Of ancy
eplp*lth.VT.d agent
TOTAL:
i
OFFICE COPY