20175 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlflcatlon PERMITNO.
� BeB�din�'i^Ao�oyg ir r ,l pG r wA — Guy, 20175
`1 LxL 1 a L_I N J)L one. CITY OF CUPERTINO-BUILDING DIVISION
APPLIC
Cc mactor.Name: Lie.No: APPLICATION /PERMIT
j3ot� C-M- z M4.1 YY/Ly 2G55 6l BUILDING-ELECnUCA4PLUMBING.MECHANICAL CATEGORY CONTROL«
Ar Mleci gineer Lie Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under pravisionsof Chapter 9(commse. APPLIANCES-RESIDENTIAL JOB DFSCRE'TfON
tngwlth Secilon 7D00)of 1Xvislon3ofthe Businessand Profestlons Cade,and my
license is In tor�gapy t.0 - rr PANELS
Licenses In ft�L lcffe
DateC{Q Contractor UP�r�
7 r /—! `�ARCHIractor fj-ECrCAR 10 T` UPT O2AMPS
DOAM
p�p�uu N ZO ro
I understand my pla .hall be used as public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA $/EQ.FT.
Licensed Professional SIGNS ELECTRI L '
OWNER-BUILDER DECLARATION SI'Ff_ULCIRCUI LSC
71., UUU� IherebyafBrm that lameaempt(rom the Contractor's License Law for the
O ❑ following reason (S
. ectlon 70115mi,Business a Peafmbns Code:Any city or .MELTROR INST
r^'a countywhichrequimapem two mtmR,alter,impmve,de=lbh,orrepair
any structure prim to its issuance,alsorequireethe appllrantfonuch pernotto
Ofile a signed statement that he Is licensed pursuant to the provisions of the DEIgCE
Contractors License Law(Chapter9(commencingwlth Sectio 7DOO)of Divi- NG ELE
Crkk
F,�OS s1on3 of the Businmand Profmloru Ceds)orthat he is exempt therefromand VALUATION
the bash for the alleged exemption. Any violation of Section 70715 by any G'(,
fA
<� applicant for a permit subjectsthe applicant to a ciell penalty d natrrorethan Off- ICHFS /9 � J��(7
c. fiv�e,f�undrcd dollars($500). NEW R: L 772 SQ.FT. STORIES TYPE CONSTRUCTION
�n u I,as owner of the property,or my employees with wages a their sole
compensation,will d o the work and the structure is not Intended or offered for
Osale(Sec.7044,Business and Profmiom Cude:The Contractors License Law
�$ does not apply to sax owner of property who builds or improves thereon,and
E who does such work himself or through his own employees,provided that such OCC.GROUP RFS.UNITS
improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement iswldwithlnoneyearofcompldiogthe ownerbull erwlll have
itrden of proving that he did not build or Improve for purpose of sale.. QTy. PLUMBING PERMIT FEE FLOOD ZONE
6u L as owner of the properly,am exclusively contracting with Ilrensed
contractors to construct the project(See 70K Buslnm end Profoslons Code: PERMIT LSSUANCE
The Contractor's License Law does not apply to an owner M property who ALTER-DRAIN k VENT-WATER(EA]
buftd.or Improves thereon, and who contracts for such pWjeds with a
co,Bjlacteu(s)licensed pursuant to the Contmomas License Law. BACK PLOW PROTECT.DEVICE "FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY y N_Owner Date RECEIPTM
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby.(flan that 1 have o certificate of consent to copy
ora RECEIPT'«
certificetc of Workers Compensation Insurance ora rertl(led copytherea((Sec' GAS G.SYSTEM-1 INCA OUTLETS PARK FIB7 Y N
3800,Leis C.)
Policy« W G G !J b/ol'1—C/ -RECEIPT x
Com any S.s ORR 10l� lar uN 4L_- GAS F.A.SYSTEM-OVER 4(EA) BUI LDING DIVISI ON FE ES
on
copy brc
hereby d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy h filed withh the the city inspection division.
r CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP. PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ft. Date Recei to
(Thor sectd ion need rabe completed If the permit h for can hundred tlollara
(S]00)oifyth which WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Irenot thatht any permuInanynce of annex an sa toblos pesubjecrmit Is booed, —
I shall not employ any person In any manner ro a to become subject to the WATER SYSTEM/TREATING
Workere'CamFensatlon Laws o(Califomh. Date PAID
O Z ApplicantDateDate Recei tN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL ELMS, SQFT,
V- should bee subject to the Workers'Compensation provisions of the Labor TOTAL:
N code,you at forthwith comply with such pnevhians or this permit shall be
deemod revoked. BUILDING FE'
dO CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby.ffirm that there is a construction lending agency for the perform- ELECTRIC FEE '
D ante oftheworklor whichthh permh hauTOTAL:
it
VO ed(See.3097,CIv.C.) PLUMBING FEE
Lender.Name
LL F Lender.Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0W l certilythat l haveread this application and statethattheatenInformation
h correct.I agree to comply with all city and county ordinances"'d nate laws PERMIT ISSUANCE FEES PAID:
} IL relating to building construction,and hereby authorize representatives.(this
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDTOMECH. DRIC ReCel N1
V - (We)agree to save,Ind emnlfy an d keep harmless the City of Cu pert loo p
aga WtBabllities,jodgmants,cootsand expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
g tai City n en o(thegmotlegdthlsprecat.
q_'(7_9 , AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
a t�re of Appl�t/Contractor Date EYHAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllitheapph rd or future building occupant store or handle hazardous HEATING UNIT(TO 100,OWBTU) Date ROCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cody Rion 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: a
❑ Ye. o
Will the applicantcar uturc building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontaminants as deflned by the Bay Area Air
Quality Management Dls rlct2 BOILER-COMP 0HP OR 100,0(X]BTU)
Yes o PAID[ h] ye read the baze ouo.tenab requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) y-A a/�
the California Health k Safety Code,Sections 25505,25533 and 2:534.1 a'R-ie.p
understand that if the building does not currently have a tenant,that it h my NEW RESIDENTIAL MECH. S'Q.FT. rr T p
responsibility to notify the occupant of the requirements which must be cost
oissIlt�f �' 7 - Jo
prix uanceofaCertl! a of 0c anry. ! fg
S -Try-rfb t31
der or authorized.gen Date enP
TOTAL:: ISSUE '�4'i
OFFICE COPY