20511 (2) APPL[CANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
k'Building Address: .
.2 o s vc sus c�e� (v-o� 20511
ro come: �1�
IQ .r'1'-- 'J CITY OF CUPERTINO-BUILDING DIVISION qD
Con actors Name: Lic.No: APPLICATION If PERMIT
e,,,r Z BUfLDING-ELECTMCAL-PLUMBINC-MECHANICAL CATEGORY CONTROI.p
Archite r. Llc.Na:
QTYELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adams.:
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
withSy on7OE.that Ism licensed3.fth. edp salnneal Chapter ode,. deme- APPLIPANEL NCFSRESIDE L J06 DESCRIPTION
Ingwith SeMon 7000)ofDlvldon3 ofthe Buanessand Profue(onsCode,and my y.�
license lsln(uB anddfect. PANELS
Wan la Lk.Cont e l d k
Date Contractor D 201-1 WO AMPS D wL.o l rtt
ARCHITECT'S DECLARATION
µQ!�ZCO I understand my plans shallbe used as publicremrtls. OVER 1000 SQ.Fr.FLOOR AREA $/SQ.FT.
E z(/ Licensed Professional SIGNSELECT'RIC L
d� FP OWNER-RUILDER DECLARATION SI'ECIALCEICUIT/
Iheabyafl.that lamexemptlromthe Contractor's LicenmlAwforthe
op following reaaan:(Section 70'11.5,Business and Professions Code:Any city or
P� countywhich requbna pertNttomvtrw],alter,lmpmvgdemolhh,or repair TEM ETPR ORINST.
prionto
a any swdsaretatemet Wt he
Iboredpursueat to the rovisihperfNte EVICE
V file a echoed statement that he t llcenaed pursuant it the tion on Of the
Cw Contndorb Llceree Law(Chapterg(mm)mthat e1sex nptt 00)ofDivl-
��OS Non3o(the Buelnessand ProfessbnCode)orthat hebexampttherc(romand S fl"E �/VALUATION D
the basLt for the alleged exemption, Any violation of Semon 70315,y any OUTLE {FSflXTI / V a a
rM?c applicant fore permit subjects the applicant to a civil penalty ofnot nnrethan
five I,asodneroft dollars epro NEWRM AL ELEC M"fir TYPE CONSTRUCTION
�n ❑Leaowneroftedproperty,oemy employenot Inwagesn thelesole
sale 5ccompesation,Business
ess andothe Pr fd thestmde:The C ntract r or Licoffere.
Law or
O sale(Sec.does not pply to anowandfropert uCoda The or impdw's License Law
(�j $ n,and
whoclussuch
losnownerofthimliywho bullas Orlmprovolhercatsuch OCC.GROUP RFS.UNrl5
EE: whoaaementsworked�elded
or ffered for ownemp,however,ovided
ilding r _
improvements am intendneyearfcompletio.theoweveg deer ill have TOT L:
Improvement bsold wlthlnoneyearofcomplaloM theowner-builderwlll have
t"mien Of proving that hs did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
II L as Owner of the property,am exclusively on meaning with Ilmnsed PERMIT lSSIJANCE
contract.to conatruct the pro)ed(Sec.7044,Business and Professloro Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WAIIIt(EN
Wild.Or Improv.thereon,and who contracts for such ptojern with a
cryR(ador(Q Bcemed pursuant to the Contradw'e License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
DRAINS A,GOND.FLOOR ROOF,ARESANITARY Y NE
IT
Dae
Owner
WORKMAN COMPENSATION DECLARRECmTp
ATION pD(TURES PER TRAP SCIi/X1L TA% Y— N
E:],hereby affirm that I have a certificate of consent to self-insure,ora RFCEO"r N
artlficet_ofWofluds'Compevatlon Insurance or a certified copythereof(Sec.
3800,lab C3. GAS EA.SYSrPA1-t INCA OUTLETS PARK FEE Y N
RECE
Policy p GAS FA.SYSTEM-OVER 4 MA) DING DI'N
Com Cz BUILDING DIVISION FEES
I ICenlfied copy is hereby tthcity
e ty Inspection division.e ci
Cenfied copy V filed with the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER- STORM EA"Fr Date Remi t#
R)m Ineslon need not lx completed I(the perrtdtV tw one hundred dollars
(8100)orl that
WATER HFATERW/VENT/ELECTR - ENERGYFEE Y N
(certify that o any personhe In of the workmanner fo a to b this permit
subjed to ed,tho —
1 shall not employ any person In any manner at n to become subject to the WATER SYSTEM/TREATING
Workers'Compensation lawaot Call(omia.Date PAID
z Z AppNOICETIf, NEW RFADENTIAL PLMB. SQ.FT. Date Rami t#
Z NOTICE TO beecomesubje to
after makingC-mpdCern.lnteof Exemptle Labor
Code,shoulyou=at
aurthwit the Warlike-'such pmatlonporthis permit s Lab be TOTAL:
7 W detmedrvokeforthwithcomplywitheachprovisioroorthbperMtahalllar: BUILDING .DO
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
Iherebya!@m thatthereisad, tinction lending agency—,the perform ELECTRIC FEE
7 Z ance of the work!car which this perMt is Issued(Sec.3097,CIv.C.) TOTAL:
02 eMeraNane PLUMBING FEE
LL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cert Bythat l have read thlaapplimthmand datethat theabove Information
is correct l agree to complywith all dtyand counlyordinances and slate laws PFRMrr ISSUANCE FEES PAID:
r IL mining to building construction,and hereby euthotlae representatives ofthls
I— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indcmrdfy an a keep harmless the City Of Cupertino DatC ReCCIP[#
V agaenstllabilltic.)udgmerste,.sbandexpenmswhlch.yinanywoyaccme AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL: , 0
a ag matsMd Cit nc eryucnceofthe Brantingofthispermit
1� -h d� AIR HANDWNGUNT OVERIO,000CIM) CONSTRUCTION TAX
Signature of Apl nt/COnt,rtor at — E%HADSTH(7OD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllca est or future building oau pant store or hand u
le hardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as deft red by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: V�V'
❑Yes, M No
Willtheappllcint or future building omvpant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUAfd[211/1KFF
which emit hazardous air contaminants as defined by the Bay Arca Air N-79�1<i--
Quality Management District? BOILER-COMP DHP OR 100,000 BTU)
4 Yes No (t 4
havernia lealthhe aSoutrtode, ditloc 25505,25533 aChapter.1 of ROILE&COY(P(OVER 100,000 BTU) JUI\ Q 1990
the Cabfor t Hsf the b Safety Code, otcursntlyh have
a tenant,
that
understand that if the build Ing does not currently haveatenanq that itlamyNEW RISIDFNTIAL MECIi. SQ.FT. ,
respomlbWty,tondi(y the occupant of the requirements which must be met !11�(IE
' rupft,10priortoisane ofaCertRicateofOodpancy.
Ow,dOr authodred agent Date TOTAL: ISSUED BY: ` c 74*-p „
Lr
OFFICE COPY