20237 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bulldin Project ldentIflratim I/I O PERMIT NO.
Building Address: V �� ' �•�� • 20237
1017�3 (�
wne,s`�rL ( FAASS CITY OF CUPERTINO-BUILDING DIVISION
• Co act r'aNan z2tgillAPPLICATION / PERMIT ll
�` BULDINGELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROLN
rcF /Engineer. �d Lie No:
BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FE,aErryar��
Address _ -WZPERMITISSUANCE W
LICENSED CONTRALTO 'S DECLARATION 0
Thereby affirmt Iaml cased under provisions of Chapter 9(commenc APPLIANCF3gESIDENTIAL JOB IEUMON
ingwilh ig sion3ofthf8 slnWIO
e,andmy, �s
license o fact..NPANTIS ys
UPTC
License V k.N 11!! /
Date Contractor 2011000 M1I'S
ARCHITE SD'CLAOVER 1000 AMT'S SQ.FT.FLOOR AREA f/SQ.FT.
�Z Iundent rad myplav shag bg used apublic recrnds
COC
c+Z(a Licensed Professional ' SIGNS ELECTRICAL �a(�
<<�Q ww� fflOWNER-BUILDER DECLARATION SPECIALCIRCU1T/ML9G,
p„ Ihemby armthat l am exempt from the Contractor's License Law for the
70 following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP,MEIFR OR I'OL INST.
f'n9 county which requires a permit t000m uct,alter,improve,demollsh,arrepair
anystmctu ,prior to Its Issuance,also requlresthe applicant forsuch permitto
P ROWER DEVICE
c.U file a signed statement that he Is Brensed pursuant to the provisions of the
Contractor's License Law(Chapler9(commencing with Section 7000)ofDivi. SWIMMING LIELECT VALUATION
O slon3ofthe Busleassend Professions Code)orthat hely exempt therefromand
F < the basis for the alleged exemption. Any violation of Section 7MI.5 by any U'ILETSSWITC 1 ES
applicant fora permit subjactslhe applicant to a civil penalty of not nnrethan
five hundred dollars($500). W RESIDENTIAL .FT. STORIES TYPECONSTRUCTION
I,as owner of the property,or my employees with wages as their sale
tz compensation,wlll clothe work and lhestructure b not Intended or offered for
psale(Sec.70K Business and Prolesslors Code:The Contractors L'an eLaw
$ does not apply to an owner d property who builds or improve thereon,and OCC.GROUP RER UMTS
who does such work himself or through his own employees,provided that such
Improvements arc not Intended or offered for sale.If,however,the building er t VTPAAk2a
Improvement Issold wllhinoneyearofcomplellon,theowner-budderwdl lsve
t"rden of proving that he did nor build or improve for purpose ofsale.). QTY. L BIN ERMI FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed ppm ONCE
contractors to construct the project(Sec.7014 Business and Professions Cade:
The Contractors License Law does nal apply to an owner of property who ALTER-D iN& -WA
Wor Improves thereon,and who contracts fou such p(ajeaa with a
co,tVTactors)licensed pursuant to the Contractor's Llreme Law. TIAM FEE SUMMARY
LI 1 am exempt under Sec B It P C for this reason BA w PR FYT.DEVICE
OUTSI UP FEES
DRAINS FLooR RODE,ARPA,COND. SANITARY Y_ N_
• Owner Date RECm N
WORKMANCOMPENSATION DECLARATION FIXTURES.PER TRAMP SCHOOL TAX Y_ NN_
Ihaven
01 hereby affirm that have a rertlBcane of consent to self-Insure,ora 2pLp7PT N
certificate of War ri Compersation ln�#au.�nnre am led ropy thereof t5ec. GAS EA.SYSTEM-1 INCA OUIL PARK FEE Y_ N_
3800.Lab C.I —#f
I'10 _F RECEIPT#
Com any GAS F.A.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�Certi(Iedc pyIs em Toro W PLANCHECK FEE
GfCefll(IM ropy is Bledwilhlheellyins'eti adivislon. GREASE/WDUSTRLC FTTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- RM EA 200IFT Date Recd Ht
(This section need nae W completed if the permit Is for arm hundred dollars
(8100)or less.) WATER HEA /VENT/FLECTR ENERGY FEE Y_ N_
I certify that In the performance of the work far which this pem it Is Issued,
I shall not employ any person In any manner w u to became subject to the WATER SYS /TREATING
Workers'Compensation Laws of Callfornla.Date PAID
O Z Applicant NEWR =ALPLMB. SQ.b-f. Date Recei Hl
ZO NOTICE TO APPLICANT:If,a Ber making this Certificate of Exemption,you
should become subject to the Worl an'Compere atlon provisions of the Labor TOTAL:
CC W Code,youmostf.rthwilhcomplywithsuchp.vii.w.rthIspem tshallbe BUILDING FE
j deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
:32 once of the work for whkhlM1Is permit IsLssued(Sec.3097 CJ
U O Lenders Name �—tTY. MECHANICAL PERMIT FEE PLUMBING FEE
ly 1 sets Aaar�^p[ Q MECHANICAL FEE
on
O W Imdlfy lagree to
comply
with
all
ynd au tyorth ascent and gate
C bmrngt building comppywo,alldtyandmuntyardmanma sad sesoftws PERMIT ISSUANCE PEES PAID:
} relating ra building construction,and hereby authorize representatives of Nb
N ALTER OR ADDTO MECH.
F cit(Wr)agree to ue abnvernally aned propert rales the Cit purposes.
? (We)agree eo save,Indemnify an d keep whkhs the City of Cupertino Date ReOTAL
U agalmlllabllilids,pdgmenb,comsand expense whkh may In anywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in eon tax mmo of the granting of this permit. CONSTRUCTION TAX
AIR HANDW NG IWTL(OVER 10,000 E)
Signature of Applicant/Contractor Dare IXFIAUST HOOD(W/DUCON
STRUCIION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apph.at.,future building occupant stare or h.ad In hazardous HEATINGUMT(TO1 Date Recei t8
rnatedal as aefincd by the Cupertino Municipal Cade,Chapter 9.IZ and the
Flealrh and Solely Cad ion 25532(a)7 HETING UNIT(OV U) TOTAL:
Yen No
Willtheapplies, to building occupant use equipment or devices VENTIATIONFA INCE ID) ISSUANCE DATE
which emit hazardous air roma Mnantsas defined by the Bay Area Air dA u
Quality Management ist n7 BOILER-COMP iP OR 1W,OW BTU) / /�TT /
4Yes No Jll
have rcaa theM1 u amalerials requirements under Chapter 6.95 of BOILER-CO (OVER 100,000 BTU) qs
the Coliform.Health&Safety Code,Bret to.75505,25533 and 25534.I Of r'
Inn
oft he building does not currently have a tenant,that m NEWRF TI
DENALMECA. SQ.FT. ID?q-
respons mtifylhe.c .flhem Ire rat which mus e
print afaC c clip 3
r a ii e ' Date IOTA L: ISSUED BY:
'
OFFICE COPY