21278 APPLICANT TO PILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: n O
11034- 1p+�t�labtW DQ, . G o
ChvhersName: 1_L,n _ one: A A A
fr (�T5t ,I`rLV ��S'I3C CITY OF CUPERTIN UILDING DIVISION . 10
O_l 2
comradrn�.:Na LIc.N.: APPLIC ON /PERMIT
BUILDING- CA PLUMBING-MECHAMCAL CATELARY CONTROL N
Architect/Engineer. Lk.No: ..
ECTR[C PERMIT . FEE BUILDING PERMIT INFO
Address: I'FRh9 ISSUANCE l 4w ® �^
LIa that EDCONTRAROr pr DECLARATION - Ill
I here'. af(i 7000) lam licensed fthr u provisions Chapter m c- APP ANCESRESIDENTIAL '
Y P a ( JOB DESCRIPTION
i with Se f.lnl 00)of Divisl.n3ofthe Businnsand l'm/essionsCode,and
t case le In lull and d(ect. Y PANES ^
revs Class Lie.#�z4,oaz- (-�D�il1'en.-�lQ htOD
Dale Contractor LQ*A-• FC
ARCHITECTS DECLARATION 201-1000 M I
r4 I understand my plans shall be used upublic rerords. OVER1 0 SQ.FT.FLOOR AREA $/SQ.FT.
rcQU LicensedProfsoiRm1 SIGNSE c A
�zw OWNER-BUILD ER DECLARATION C CNT/MISE
(hereby affirm that lam exempt fromthe ContraRor9 Lirenan rthe
70. following reason.(Section 70315,Business and Pmfessions Code: city or p, OR('OLE(NST. p
countywhich requlresa permit tomnstrud,alter,improve,demolish rrepair V-1!
pm .jai anystmu mpriortoltsiswame,alsomquirestheappLcantfor mut to DACES
E O F V file a signed statement that he b licensed pursuant to the proved..of the
�y Contractor's License Law(Cha(Chapter 9(commencin wlthSection70M)ofOwl-
Q 3 c 8 NG POOL ELECTRIC
O sion3ofthe BusinessandPMemia.Code)orthathe Isexem therefromand VALUATION
444 yy the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLETSSWITCHESFIXTURES
In —
iya applicant fora permit subjecisthe applicant to a civil penalty of not norm than •.+x 'O /� q� c
rrGJJ o O five hundred dollars(&500).
�i es as their an WRESIDENTIALELECTR SOFT. STORIES TYPE CONSTRUCTION
1.as owner of C�¢
compensation,will dtothhe ework,and th rty,or struRumisnot lint nth dedorofferedfor
5 C O sale(Sec.7044,Business and Professions Code:The Contractors License Law
docs not apply to an own.of property who builds or Improv.themoq and
who does such work himself or through his own employees,provided that suchOCC.GROUP RES.UNITS
improvements are not intended proffered for sale.If,however,the building or TOTAL: 2 00
improvement bs.ld with.oneyearofcomplellon,the owner-budderwlll have
th,e_h+rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
H L as owner of the property,am exclusively contracting with,llcensed FLOOD ZONE APN
contractors to m.tmct the project(Sec 7044,Business and Pmfessione Code: PERMIT ISSUANCE cv
The Contractor's License Law does not apply to an owner of property who I ALTER-DRAIN k VENT-WATER(EA) `pQ
Wilds or Improves thereon,and who contracts for such pWjecb with a FEE SUMMARY
on,[LII[[actor(0 licensed pursuant to the Contracto,'.License Law. BACK FLOW PROTECT.DEVICE
U I Sm exempt under Sec. 8 k P C for this reason
OUTSIDE FEES
Owned Data DRAINS-FLOOR ROOF,AREA GOND. SANITARY Y_ T#
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑('hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAIT ';L s W SCHOOL TAX Y N_
certificate of Workers'Compensabon Lurana or aartllled copy thereof(Sec. RECEIPT#
GAS EA.SYSTEM-1 WCAOUTLETS PARR FEE Y N
3800.Lab C.) RECEIPT#
.Polity# GAS EA.SYSTEM-OVER 4(EA)
om
Cany BUILDING DIVISION FRES
�
CeANed copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
E]Certifed copy a filed with the city inspection division. '
CERTIFICATEOF EXEMPTION FROM WORKERS' GRFA'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.200Ff. Date Recei t# 27103
(Thissection need not be completed if the permit Is forom hundred dollars
($tm)or less.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N_
I rertfy that N the perfomunce of the work for which the,pemdt b issued,
I shall not employ any person inanymanner w.to become subject to the WATER SYSTEM/TREATING
wppic'm it of l`iss. 0 runs D6ate/}—i_q'r2 PAID
O Z Applicant d ingt NEwRmDF2.mAL PI.Me. sQ,Fr. Date Recei t# �Qt
Z O NOTICE CO PLICAM:ILa kompenshis enflcateofonsoftip Labo
should became evbjee to the Workers'Compe.atlon provblons of the Labor TOTAL
� ; Cde,you must forthwith comply with such provisions orthe permit shall be BUILDING FEE t
W G deemed revoked.
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebya(Ormthat there Is amnstructlon lendingagency fortheperform- l ELECTRIC FEE
ce2 .07
7O anof the work forwhichthb permit is Issued t$ec.3097TOTAL:
,Clv.Q sC�
Lender'.Name PLUMBING FEE o0
U Lenaer'.Aaaress QTY. MECHANICAL PERMIT FEE'..
LL U Icertfythat l have mad this application and Kate that the above information MECHANICAL FEE
O W at correct.I agree to comply with all cityand county orlinancea and state laws I PERMITISSUANCE I'L(W FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
F city to enter upon the above-mentioned property for inspection purposes. Z ALTER ORADDTO MECH. c dD
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
U a gainsthabilities,jarigmenb,mstsand expe.eswhich may In anywayaonme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a Inst. City in n the Ung of this perm t.
(/l�ypJ� uRHANDUNc ITivrr(OVER lO,000cEM) CONSTRUCTION TAX
Signau of ra�eF/F �� ace EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDO SMATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle hazardous HIATINGUMTOO100,00013M Date ReceI t#
material as defined by the Cupertino Municipal Code Chaptcr 9.12,and the
r Health and Safety Code Section 25532(a)7 I[EATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes N No
Will Cheapplicantorfutumbuildingoceupant use equipment ordevices VE14ILATION PAN(SINCLE RESID) ISSUANCE DATE
which eManagements air�nta Mnanta as defined by the Bay Area Air p qq��
Quality Management air comandrantsas
BOILER-COMP pfm OR 100,IXt0 BTU) PpIE®
Ej Yrs F� No
1havercadtheh ma(eda eq lmmensunderChaper6.95of BOILER-COMP(OVER 103,"BTU) , 4 1990
4the California Health k Safety Code,Sections 25505,25533 and 25534.I l O V U 1
understand that if the building does not currently have a tenant,that it Is,my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most W met
prior to Issuance of aCertificate ofOmupancy.
Owner or authorizeda t Date
gen TOTAL: I�a� ISSIIEDBY: �1vF✓T}'Iw w��d
OFFICE COPY