20603 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuildingAddress: v/
7 (vS
2C WOOD 20603
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Jd/9 /(7Q p p
CITY OF CUPERTINO-BUILDING DIVISION
14YLIcNm APPLICATION /PERMIT
3 10 BUR,DINGELECiRICA PLUMBINGME NICAL CATEGORY CONTROL Y
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE �.�.BBUILDING PERMIT INFO
Address: PERMITISSUANCE ��( [:] 1:1 [TLICENSED CONTRACTOR'S DECLARATION L�
I hereby ion7OButlon,vWon3licensed ftheBuimmadPmfe apter9(mmmenc APPLIANCFSRESIDENTIAL JOB DESCRIPTION
ingwltI I full 7000)ol Dl effect (the Busimasand Pro(esslonsCode,and my UO
licenselein(ullf and d(M. �TIOO
PANELSLicense AssLIc.M Date cmntraRoIT ToARC 701-1"AMPS
rcOZp Iundea mypla be . AA
AMPS / SQ.Fr.FLOOR AREA $/:Q.
(s Llcen oral CTRICAL
6 e WNER-BUILDER DECLARATION IRCUIT/MIST
H owhigr sses hat lamexempt form the Contractors License Law for the
Z O 9 @ lollowin revon.(Section 70115,Business and Professions Code:An d or
O Z F 8 Y city IFR OR LE IN
county which requires a permittoconstrue chez,Improve,demollsh,ereepalr
.a anystrocture priortoitsL ance,alsorequimstheappbantforwchpermltto VICESfile a signed statement that he is licensed pursuant to the provisions of theContractor's License Law(Chapter9(commencing with Section 70(0)of Dive- FOOL EL Csion3oftheBusinessandProfewtomCode)orthathebexempttherefmmandVALUATION
1ES�"•7 the basis for the alleged exemption, Any violation of Section 70315 by anyd 5 Ppliantfor a permit subjects the applicant to a civil penalty of not more than TC�iflue 1,as ed owner ofthe pr. EMT L SQpT. STORIESTYPECONSTRUCTION❑1,as owner l of property,or nary employees with wages , ff,i fievam(Sc.70 liestrotheworrefeashe,Code:ThmatintendedorcenseLowvie(Bt. ppy Business and Profeperty ho The lds or imp eves Licenae Tawdomnoessuchly toanownerofpmpertywhonemporimpmovided thatand
whodoeascrusam khlrtaededorough hlsownempioysea, er,the uildingor suchOCC.GROUP RES.UNITS
Improvementsarenot IntendedoroReredforsale.theo evegtWcrwdingveTOTAL:
Improvement bsold wilhinoneyearofcompletion,theowner-builderwill have
t1iLtuNen of proving that he did not build or imporve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOO DONNE APN
11 L 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 License Law does nut apply to an owner ed pmpeity)who ALTER-DRAIN&VENT.WATER(EA)
Wilds or Improves thereon,and who contracts for such projects with a
dor(s)BcenwdNmuanttothe Cmntrador'e Llame Law.
off FLOW PROTECT.DEVICE FEE SUMMARY
am exempt under See- B &P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑I hereby affirm that I have a ceniBcate of curator to self-Inmre,or a FDCIJRF_""PER TRAP SCHOOL TAX Y N
centflate of Workers'Compere ation Insurance ora cenifed copytheroof(Sec. RECEIPT M
3800.Lab C) GAS.GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y_ N_
Pality I \ 1 I_ /' I RECEB7 M
Co��mPPany� F��9RY� GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
I IcerUnea mpybhereby famished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
.aP-J�Certified copy is filed with the city Impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(Thlsecction need ort becompleted if the permit lsforonehundred dollars SEWER-SANITARY-SIORM F.A.20(117. Date Reeei to
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
1cenot thatinthe performanceofthe work in,ast become
pemdt Is booed, —
I shake not employ any perms in any manner m m to become subject to the WATER SYSTEM/TREATING
Workers Compenaaeon Laws of Date
0Z Applicant PAID
Z O NOTICE TO AI'PLICAtothe cher rs'Co pentathoiicateof Exemption,you NEW RESIDENTIAL PLMB. SQX.T, Date Recei t#
shooedbecomeforth to the Workers'Compemasonprovblumofthe Labor TOTAL:
W~ N deemedCodeyumust forthwith comply with such provisions orrhb pertNt shall be
> dressed revoked. BUILDING FEE
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b m
cea nsuunlon lending agency for the perform,
7 Z anof the work for which permit is houed(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
O O "usier'Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE
O W Icon lfythatl have read thbapplicatFn andatate that the above information MECHANICAL FEE
b Correct l agreetocomplywith allcityand countyordlnancesand state laws PERMIT ISSUANCE - FEES PAID:
} d relating tobullding consuictlon,and hereby authorize representatives of this
F. N city to enter upon the above-mentioned property for Wpectlon purposeER
s. ALTORADDTOMECH.
Z (We)agree to 79 !-17deg�.
efy an d keep harmless the City of Cupertino Date Reeeiptill
agmeatllnbilltfix, xre nichmayinanyw.yaccom AIR HANDLING UNIT(TO i(ifu0 CFM) SUBTOTALagalmtsaidClIue ting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gnaturc of Ap t/ actor Date EYHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturebuildingoccupantslomorhzndic havrelous HEATING UNIT(TO IMODD BTU)
malerblaadefined by the Cupertino Municipal Code,Chapter 9.12,andthe _ Date RCCCI t#
I4althand Safety Code Scctlon25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTAL: �,
❑ Yes M No
Will the applicant orfuture Wilding occupant use equipment or devices VELAR LATION FAN(SINGLE RESID) ISSUAN EDATE
which emvacosta it hardous air cominants as defined by the Bay Area Air
Quality Management Distad? BOILER-COMP OTIP OR 100,M BTU)
Yes ❑No
. ave read the hazardousmatedalsrequim=ntsunderChapter6.95 of BOILER-COMP(OVER 100,000 BN) ��.I OJ t�j ItJ J�
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIALMECH. SQ.Fr.
responsibility to notify the Occup int'of the requirements which most W met
prior to issuance of a Certificate of Occupancy. p'qJ GBR21tIRQ
Owner or authonud agent Dafe �4.�C,��� .r1}},� y,,
TOTAL ISSf1EDBY:IJ VSY�TV`J Vv�+nyl
OFFICE COPY