19869 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proles Identification PERMITNO.
Building�d o 3 a 19869
n n ams: Phone: AppuZWT Tr
CITY OF CUPERTINO-BUILDING DIVISION Gt�j k—R-0
c tr.Rar'aN LIr.N°: APPLICATION / PERMIT
�Gz BUILDINGELECTMCALPLUMBINGMECHAMCAL CATEGORY CONTROL
hltect/Engineer. Lk.No:
/ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:;'�,Op 9s k O ❑
PFRhIITISSUANCE �
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions°(Chapter9(mmmen APPLIANCES-RESIDE L JOB DESCRBrfION
Ingwlth5ection 7000)o(Dlvlalon3ofthe Buslnneand Pm(csalona Code,and my
"Id's bmmBJ9rre. adren. yo 6 2�/ PiW°s
Llcen ism � Lk.N
Date Contractor
ARCHITECTS DECLARATIO Cb 701-1000AMPS
O
Z I understand my puesshxBbe usedmpublic m0amL OVER1000AMPB SQ.FT.FLOOR AREA $/SQ.FT.
CO
U()Licensed Professional SIGNS TRICA
Uqy
6 OWNER-BUILDER DECLARATION SPECIAL MISC
7 IhsmbyafErm that Iam exemptfrom the Cont factors License law for the
pp❑ following reason. 70315,Business and Professions Code:Any lily or
OW
r,�F'eq county which require a permit to const ict,alter,Improve,dem ll ,orrepa)r TEMP.ME EI T.
g as any structure prior to its issuance,also requires the appBont for such permit to POWER
L� (� file a signed statement that he is licensed pursuant to the prep slom or Ne
3a. Contommr's License Law(Chapter 9(commencing with Section 70W)of ONE. SWMIKHOCPOO E C
s n3oftheBus mandPmfemlomCode)orlhathebexemptlherefmmand VALUATI�
Q the basb forthe alleged exemption. Any violation of Sadion 7031.5 by any OUTLETSSWITC FI
applicant fora perrmbubjecb the applicant to a civil penalty of not more than
five hundred dollar he Elm NEW RESIDENHA EL SQ.F7. STORIES TYPE CONSTRUCTION
�n e as owner of the properly,or my employees with wages r offered
sole
compensation,wusBotheworkandthes Code;
durch nm Intended or offeredfor
O sale(Sec 7064 to Business and f property
Co builds Comproves Ihemor law
does notwhodue apply torn owner ofp rough who nemporlmproveslhercoryand OCC.CROUP RES.UNITS
whodoements asuch worknor intenlf or ded
orwgh hbowae,If,ho es,provided that such
improvements t am nor Intendedearofco forn4.If,hawevee the building
ve TOTAL:
Improvement Iswld withmoneyramfcomplellory Iheowner-bu0derw0l have '
the burden of preving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE.
7 L as owner of the property,am exclusively contracting with licensed FLOOD ZONE MN
contractors to construct the project(Sec.70K Business a"Professlora Code: PERMITISSUANCE
The Commeto(s License Law don nor apply to an owner of property who ALTER-DRAW k VENT•WATER(EA)
Wilds or Improves thereon, and who contracts for such ptEjects with a FEE SUMMARY
•R6pnor(a)licensed pursuant to the Contractor's License law. RACY FLOW PROTECT.DEVICE
r, U I am exempt under Sec. B k P C for this reason
BEA,CONI. SANITARY Y N
Owner -
Date DRAINS FLOOR ROOR,A RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT N
3800lab of Workers'Comperwtloniruurance ora certll4d ropytherro((Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y N
pwl Lab C.)---/PC OSY=_C� DING DIM
Poilry N CAS EA.SYSTEM-OVER 6(EA)
Com anv BUILDING DI VISION FEES
�Certlfled copy b heed with t ecity GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
I171Certified ropy 4 filed with the city Impx2lon division.
Y' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE Sb}yp-R-SATARY-STORM E.A.20QFT. Date Regie) t#
(This section need fiat be completed If tM
he pdrut is for one hundred dollars
(SI I rdlifess3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Ill of halo the performance of the work so as I.
pesubjec Wund,
I shall fiat a ley any pe In any Wanner at as m berona subject to the WATER SYSTEM/TREATING
Worken'C nsatbn Lyy�p (�a0ornla.Date PAID
O' A Ilam a O A OC7 /a 4w. __ NEW RESIDENTIAL PLMB.
Z Q Nd7mhlu CAM:H,after making thisk of Exemption,you SQRT. Date Recel t#
should hero subjecttolhe Worken'Compe tlonpmvblomcfthe Labor TOTAL:
cN Code,you must forthwith comply with such provislom orthb permrevmit shall be
BUILDING FEE
W 7 damned..ked.
a o CONSTRUCTION LENDING AGENCY SEISMIC FEE ( 92
I hcrcby affirm/hat there b a ronatmctlon lending agenry for the perforrm ELECTRIC.FEE
Z ante or the workfor which this permitbbeard(Sm 3097,Civ.C.) TOTAL:
00 [.Mae.Name PLUMBING FEE
F Lender's Address QTY. MECHANICAL PERMIT FEE
OW IcerUfythallhavereadthbapplicalbnanddltethattheabovclnfomutlon MECHANICAL FEE
1 IarorrcR.Iagreelocomplywith Wcityand coontyordinancesand stalelaws PERMIT ISSUANCE FEES PAID:
>. N relating to building mmtruction,and hereby authorize representatives of this
H Z Aly toenter upon the above-mentioned property for Wpectlon purposes. ALTER OR ADD TO MUCH.
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,pdgmenb,coslsand expenses which may In any way accrue AIR HANDLING UNIT(rO 10,000 CFM) SUBTOTAL:
.east said City in 7ce of the granting of this permit.
I //`7D AIR HANDLE NG UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Si a roof AppBct
ant/C°ntmor 11 Date RXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
a HAZARDOUS MATERIALS 131SCLOSURE
WllltheappBum or futumbuildingouvport store or handle hacardous HFATINGUMT(TO100,000R7V)
materblasdeflaed bylhe Cupertino Munidpa1Code,Chapter9.12andihe Date Recces t#
Hnithand Safety Cad ction25537(a)1 HEATING UNIT(OVER 100,00B BTU) TOTAL:
❑ Yes No
WIII Ihe3pplianto future building occupant use equipment or devise VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
QjLlity Management Dls NO ROLLER-COMP DIE'OR 100,000 RTU)Q Yes ftly
Wve read the haranTm.materials requlrcmnntsunderChapler g,95 of BOILER-C'OMP(OVQt 100,000 BTU) ���
the California Health k Safety Code,Sections 75505,25533 and 25536.1 r �a
understand that ifthebulldingdoesnot currently have a tenant,that it b my NEW RESIDENTIAL MUCH. SQ.FT.
resp mlbiltry to notify occupant of the requirements which must be met nt
Fri r oissuanceo CertiflateofOccupanry. W�
r//_yo '^''��}}�1���� f� x
Ow �rorauthorizedagent Date ISSUEDBY71)a
TOTAL:
OFFICE COPY