20570 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tluilaln Pro'art lacntiflntlon PERMIT NO,
Building Address:10 ^Orn O 2 GL r ru e G •V1 I
one:
• q G� �, ylI,,(.,Q CITY OF CUPERTINO-BUILDING DIVISION
convaaotawm: /
Lie APPLICATION I PERMIT
-rOla)Y G3 ANGOL,a� 33oZ� BUILDINGELECTRICA PLUMBINGMECHANICAL CATEGORY CONTROL If
Aahltect/Eng( n Llc No:
QTY ELECTRIC PERMIT "', `FEE BUILDING PERMIT INFO
. Address: PERMIT ISSUANCE /� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth Section 7000)of Div(slon3ofthe Buslnnsand ProfeaslonsCodeand my
license Is In full force and effect. PANELS
Ltmnw Clam Llcp
Date Contractor l
ARCHITECTS DECLARATION 201-1000 AM '
pZ Rundentand mypiansshalbeusedupub0c.Ms. ' OVER 1000 PS SQ.FI.FLOOR AREA $/SQ.FT.
qO
Ob O Licensed Professiorul SIGNS EL CAL
< ° OWNER-BUILDER DECLARATION SPECMLC T/
Pp, 7a I herebyafOren that lam exempt from the Contractor's License Law for the
qq following reason.(Section 70315,Business and Profeselons Code:Any dry or
..tywhichrequiacsaPermitmmmtmd,altepimpmve,demolbh,orrepair ' P.MEHBO LEI
33 a nystm=mprlortotteia ancgalsomquimstheapplimAtfmwchpermitto PDQ�Rp
MX
O6 a signed datement that he 611ansed pursuant to the provisions of the
O u,t�, Contractor'.License Law(Chapter 9(commencingwith Section 7000)ofDIW-
�OS sionI mile Btdneesond ProfessionsCode)orthat he 6 exemptlherefromand S NG L C VALUATION
AM
Gthe basis for the alleged exemption. Any violation of Section 7031.51 y any OU7LE*TC }7
applicant for a permit subjects the applicant to a civil penalty of net nacre than
ofive hundred dollars(5500).
F-11,as owner of the property,or my employees with wages as their sole NEW ELEC �'�' STOW CS TYPECONSMUCTION
7Q rompenmIion,wlldo the work andthe structure b not intended or offered for '
q sale(Sec.7044,Bus=s and Professions Code:The Contractors Limns.Law
$ does not apply to an owner of property who builds or improves theater,and OCC.GROUT' RFS.UNITS
0. who don such work himself or through hisown employees,provided that such
improvements arc not Intended or offered for sae.If,however,the building or TOTAL:
Improvement is sold within one yearofcompletion,the owner-bullderwill have ,.
tIl£j ben of proving that he did not build or bnprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively mntraning with I—a— PERMIT ISSUANCE
rontraclon to construct the project(Sec.7014,Business and Professions Code:
The Contractors License Law time not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild. or Improves contracts,thereon, and who contfor such projects with a
c=pctor(8)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE" FEE SUMMARY
LII am exempt under Sec. B&P C for this reasonOUTSIDE FFF—S
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECEIPTM
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
(�ereby affirm that I have• ax-ra to of consent to self-insure,ora RECEIPT N
mnNnte o(Workeri Com nsatlonlnsurana ora nrtlfled ropythenrof(Sec. GAS EA SYSITM-I INCA
3800,Lab C,) [' C PARKFM Y N
Policy8 6' 6Q O RECEIPT
Com an GAS� F.A.A.SYSTEM-OVER 4(E_�(� BUILDING DI VISION PEES
&CeatiRe°copy is nereoytehed. IGREASE/INDUSTRL WASTE INTERCEPTOR PLANCt-IECK FEE
�[endied copy 6 filed withh the dty Inspection division.
CERTIFICATE OF FXEMPTION FROM WORKERS' GREASETRP PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date R.i
Ohissectlon need not be complated If the permit b for ane hundred dollars Pt#
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
Ill not that employ
an pens in any tramar so as to b. subject
issued, —
R shall not employ any person in any manner w u to become subjm to the WA7.ER SYSTEM/TREATING
Worlicant mpensatlon Laws of California.Date PAID
O Z Applicant
Date Remf t#
Z O NOTICE TO MPLICANT:I,after nuking this Certi(Inte of Exemption,you NEW RESIDENTIAL PCMB. SQ.FI'.
should become subject to the Workers'Compensation provldmu of the Labor TOTAL:
— Code,you must forthwith comply withinch provlsioro or this permit shall be -
> deamea re.W. B •••
G
CLCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there 6 a construction lending agency for the perform. ELECTRIC FEE
Z arm ofthe work for which this permit is Issued(Se,3097,Civ.C.) TOTAL' ELECTRIC FEE
V Leader'.Name
LL I— Leader'.Aaaress QTY. . . MECHANICAL PERMIT., FEE., MECIiANICAL FEE
OW 1certify shall have read this application and datathattheabovelnformation
C is corract.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives ofthis
H Z city to enter upon the abovamanlloned property for inspection purposes. ALTER OR ADD 7O MECH. Dale Receipt#
_ (We)agree to save,Indemelfy as d keep harmlass the City of Cu pen too
against liabilities,Prigments,ronsand expenses which may In any wayaatue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag said Clty In ron.eque 5e (the grant Ing of this permit
e 9 .y AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
'
X�Sl�atme p�3ppunnt Cammeter Data IXHAUSr HOOD by/DUCT) CONSTRUCTION TAX PAID:
v HAZARDOUS MATERIALS DISCLOSURE
Will theapPOnnt or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Remit#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant.q
zafi
tum building occupant use equipment ordalom VENTILATION FAN(SINGLE RESID) ISSl�1
9N�E.Dapplicant.q9N�E.DATEATE
which emit hardousdrcontaminants..defined by the Bay Area At, FAi LLJJ
11ty Management District? BOILER-COMP OHP OR 100,000 BTI))
a Yes Q(''�Nn . = lyyU
have readthehazar�o..materiabrcqulrementsunder Chapter6,95of BOILER-COMP(OVER 1fA,000 BTU) JV:1 �.
the Ca lifemia Ilealth&Safety Code,Sections 25505,75533 and 25534. 1
understand that if the building don not mrrentiy have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.Fr.
reporuWBity to notify the occupant of the acquirements which must be rtM .t• .
prior to Issuance of a Certificate of Occupancy. ahj Q``! CBpertgypinn
Owner or authorized agent Data ISSUED BY:,a L.
TOTAL:
OFFICE COPY s