21123 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY o
Building Pm cct Identification lel— 2.,3 FERM NO,
Building Add 3; //�� 2 1 1 n 3
� U 3 G I I G VS
weer. ams: ore: APPLICATION SUKMHTAL DATE
CITY OF CUPERTTN0.6UILDING DIVISION �0^�r--qO
• contra or'eN LIc.Net APPLICATION /PERMIT qI
r D" yµ�^�7�.T /�'� /��Oi7/ BUILD)NGELECTRICAL•PLUMBING-MECI IAMCAL CATEGORY CONTROL Is
Arch Ea e G-'pUtp Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Addrau: PERMITISSUANCE "Liz I� �Q (Q
LICENSED CONTRACTOR'S DECLARATION L�] L� LIP'
I hereby affirm that l am licensed under provisions of Cha Ater 9(commenc. APPLIANCF2LRESTDENfIAL TOB DFSCRR'OON
Ingwlth Sedion7000)of Dlvlsian3ofthe Butlnessaad Pf�feast Code,and my
Ilrense le In(u and effect Lid
/1,
N PANELS ��
Liren(�C s�Lk.N_____ /
Da[e Contractor_ ' (L
ARCHITECT'S DECLARATION 201'1000 AMPS
q�q�vv aO ZpC l understand my plana shall be used a public records. OVER 1000 AMPS SQ.Fr.PLDOR A��R..((E,,A S/SQ.Fr.
Fi'ouyu Llrensed Professional SIGNSE C L 1 36
OOWNER-BUILDER DECLARATION NrECu C L,
y� -4 1herebyaflrm that l am exempt from the Cuntracto'.Llrenae Taw for the
following reason.(Section 7071.5,Businessand Profession.Code:Ancity.,
��[[
p, cauntywhlchmil.lresa permit to construct,alter,Improve,demolish,Any
TEMP'
anystm=mpriortoibh ancgabomquimtheapph.ntforvuchpermitto NNO � OWN as
file a Ned statement that he h licensed pursuant to the provisions of the POWER DEVICES
Ole ComnxEes Licence Law(Gupmr9(commendngwlth Section 7000)of Owl.
�O slon3 oftheauslnem and PrefesslonsCode)orthat he h exemptiherefromand SWIMhBNG1 it VALUATIONQO
the bash for the alleged exemption. Any violation of Section 7031.5 by any
aPpBont for a permit subjects the applicant to a civil penalty of not aarethan OUTLETS—SWITCHES-FIXTURES
Ove hundredeof the pro NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑I,as i..,owner l the property,or my employers with wages a thele soar
compemotion,w111dothewarkfeanim,Coda, hr Contractor oroffereLaw M
O doe(Sec. pply 70K to animeandf property
Code The Cimprovrs heerue Taw �ltJ
don not apply loan owner of pro ugh his
anems or improveswvided tory and OCC.GROUP RES.UNITS
who doeeauch work himself orthrough hbownemployns,provided that such
improvements;are not Intended oroffered formic.If,however,thebullding orTOTAL: t
Improvement hsold within one yearofmanpletion,the owner-builderwlll have
tl�*rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
Lf 1,as owner of the property,am exclusively mntratling with used PERMIT ISSUANCE
contractor to construct the project(Seo 7019,Business and Pm enWm Code: 4J
The Contractor's License law don nor apply to an owner of property who ALTER-DRAIN k VENT•WATER(FA)
builds or Improves therects
on,and who contrach for such Implewith a
��t..[[ac4or(s)Bmnsed pursuant to the Contrattorl Llcenx Law. FEE SUMMARY
LII am exempt ..it.,Sec B 9s P C for this mown BACK FLOW PROTECT,DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N-
-Dam• Owner ECL RECEB'rN
WO IKMANrmthat COMPENSATION DECLARATION F0(TUREq-Egg TRAP SCHOOL TAX Y N
❑l hereby affirm that I have• lmum to of consent to pythemof ora RECEIPT N
380 i,abof Workeri Compewlionlmurenre ora rertlfled ropythemof(Bac. GAS,EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
3800 Lb C.7
Poliryp — RECEIPT is
CamCnrtYfiGE .SYIVER4EA)
ed
BUILDING DIVISION FEES
copy is hereby ttheed
city inspection division.❑Certified copy h(Teed with tCREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
city
CERTIFICATE OF EXEMPTION FROM WOR K ERS' CRFASETRP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 2XIFT Date Recel ti
(This section need not be completed If the permit h forone hundred dollars
($100)oily less.) WATER IR;ATER W/VENT/ELECTR ENERGY FEE Y N
Irertifythatln aniphe eo ninaof the week for tobthlapemdtla Issued, —
I shall not employ any person In any Wanner•onto become subktt to the WATER SYSTEM/TREATING
Workers Compensation Iowa of California.Date PAID
O Z Applicant NEW RESIDENTIAL FILMS. SQ.Fr. Date R2T! HI
Z 0 NOTICE be. stbJettothe a@ermaldomperng this Certificate is Exemption,you
should become subject to the Workers'Compematlon provisions of the tabor TOTAL:
fA Code,yma at forthwith comply withsuch provlslomorthh pernitahallbe O a
5-0
9 deemed revoked. BUILDINC FEE
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE 17132
I hereby affirm that there Is a mretmctlon lending agency far the perform ELECTRIC FEE
M Z anceoftheworkforwhlchlhle perMthhsued(kc.3097,CN.C.) TOTAL: 1 D
00 LeadereNarae PLUMBING FEE
LL H Landar'u Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (y
O W I achilythatl have read this appilcaBanand statethat the above lnforrution ,,aappp�
C Is correct.I agree to comply with all city and county ordinances and Ads:.. PFRMITISSUANCE 2a 1N..9 FEES PAID:
>. N relating to building construction,and hereby authorize representatives of this
Fcity to enter upon the abovtmentbned property for inspection purposes. ALTIRORADDTOMFLH.
Z Date ReCCI Ile
— (We)agree to uv demnlfy d keep h he City of CupertNa P •�
agaimthid, ❑eq' ..'=. ndex swhe maylnanywaysee AIR HANDLING UNIT DO 10,000CFM) SUBTOTAL a- \
against conanqu o(th statin Is permit.
AIR HANDLING UNIT(OVER IQODOCFM) CONSTRUCTIONTAX
a urc of Apok6ruifContratetordeEXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC SURE
Will the applicant w future building ottupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Reoef IN a
nutedal as dented by the Cupertino M.Ndpal Code,Chapter 9.17,and the
health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Y. M No
Wllltheapplicantorfttum building oavpant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air centamimnla as defined by the Bay Area Air
. ality Management District? BOILER-COMP OUPOR 100,00)BTU)
Yea (❑''oNoAN
havatead the
ealth&rdfety Code,
requirementsunderand 25534.
of BOILER-CONP(OVQt 100,000 BTI))
ifie Glifornla Healthk5alety Cade,Sectlom 25505,75533 and 75534, 1
understand that If the building does not currently have a tenant,that It h my NEW RESIDENTIAL MECH. SQ.IR.
responsibility to notify the onvpant of the requirements which at be met O Jp�,v 1'�ltl
prior to Issuaareof a CertlOatc of Oavparry.
Owner or authorized agent Date
TOTA4 ISSUED BY--
OFFICE COPY