20168 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PEMWT NO.
Buildinga�1 LANPLtC FHarr2 sq 122 20168
ere one: A A
aCQlJGH ^ W, wry CITYOFCUPERTINO-BUILDING DIVISION n�
co radnr'.Na LLir.No: APPLICATION /PERMIT Co7--/ 0
6 /.lo D SO BUILDINGELECTRICALPLUMBINGMLCHAMCAL CATEGORY CON-ROL p
Architm Engineer. Lic No:
QTY' ELECTRIC PERMIT - FEE BUILDING PERMIT INFO, -
Address: PERhBTISSUANCE 1:1 ❑. ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby Sacro 7000),7 ivislonsed 3 oftheunder inessa and ns of
Chains 9de,and my APPLIANCES-RESIDENTIAL JOB 13 S 101'TION
Ing with SecHon7(1(Tl)o(Divlpon3o(the Bupnessand Prolesslons Code,andmy
license b d effect. 1� /-/ PANELS
License C�yae�—Lk.p J `! GN., �',N�y �j�yP.4 IT,
Date �Ji�/bntractor r
��.^' aLRLH1TEC1`5 ' L ATi N �2 201-1 OOO AM)5
QZO l understand my plans shall be used as public records. I OVER 1(DO AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
.do Licensed Professional SIGNS ELEC AL
Z
Q w OWNER-BUILDER DECLARATION
In PS SPECALCEiCUI M
i.., owing reason.
C halonat I 7 31Z,l from heti i Contractor.License Any dt the
Z O—� following reazon.(Semon 70315,Businss and Professions Code:Any dty or M
Opr' «vntywhich requheea permit tommtruct,alter,Impnw:demo8sh,orreppr P. ETGRO EI
F a-t anystmMmprlortoiUus ance,alsorequirestheappBc "it'such pemdt to D�
file a signed statement that he is licensed pursuant to the provisions of the
Contracmr9 License Law(Chapter 9(commencing with Section 700D)of Divi-
I..,OO�' aionlolthe Bupnm dProfe i.ns Code)o,lhattheuexem,"hZremmaed S NG ELG C �y VALUATION
o O the basis for the alleged exemption. Any violation of Section 7Q715 byany OSE
i5d applicant for a permit subjects the applicant to a civil penalty M not more than `
five hundred dollars($500).
NEWRE I ENTIAL L IR .FT.
7 ❑I,as owner of the property,or my employee with wages r their sole STORIES TYPE CONSTRUCTION
rom(Se,7 KB. doth.work andthestmdure Vnotintended orofferedfor
sale(Sec 7044,Business and Professions Code:The Contractor's License Law
p�$ doeanot apply to an owner M property who Wilds or improve thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
improven
runts are not intended oroffered for sale.I(however,thebullding or TOTAL:
Improvement usold withinoney arofcompletiogtheowner-builderwill have
the Wrdenofpmvingthathedid notbuildorimproveforpurpmeofasle.). QTY.I PLUMBING PERMIT. FEE FLOOD ZONE APN
❑I,as owner of the property,am exclusively contracting with Licensed PERMITISSUANCE
contractors to constroct the project(Sec.7014,Business and Professions Cade:
The Contractor's License Law does not apply to an owner of property who
W03 or Improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA) -
c`ff1c..a licensed pursuant to the Contractor's License SUMMARY
nse Law.
LJ I am exempt under Sac. e&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
OwnerDate DRAINS FLOOR ROOF,AREA,CONE. Y N_
SANTEARY ,
RECEIVE a
WORKMAN COMPENSATION DECLARATION FIXTlJRFS PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate cone of consent to pytheureora RECEIPT X
rerti(irne o(Workeri Compensatlonlnsuranre ora rertifled ropythereof(Sec. CAS EA.SYSTEM-1 INC OUTLETS PARK FEE Y N
380,Lab C.) RECEIPTN*
o
2 Paliry p GAS EA.SYSTEM-OVER 4(EA)_ CAm BUILDING DIVISION FEES
C.rllfied copylahereby(urnlshed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy u filed•vilh the dty InspMion division.
- ' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(IOF I'. Date Remi [#
(rhlssedion need not be completed if the permit isfor one hundred dollars
(8100)orless) WATER HFATQt W/VFM/FI.ECTR ENERGYFEE Y N
I rertlfythat in the performance of the work for which this permit is Issued,
I shag nut employ any person In any mune,so as to become subject to the WATFI?SYSTEM/TREAUN'G
Wdrkeri m
Copematien Law.ofCaummia.Date PAID
z Z Applicant - NEW RESIDENTIAL PLMB. SQ.FT. Date Reeei t#
Z O NOTICE TO esubje AtotheWafter rkerukingttes ationlcate of Exemption,you
Hshould become subject to the Workers Compensation pme"teafthe Labor TOTAL:
cN Code,you most forthwith comply with such provisions or this permit shall he BUI NG
> deemed revoked.
W ELE
_ CONSTRUCTION LENDING AGENCY SEISMIC FEE 1Su
Il ' 1h.rcbyafflrmthat there is a construction lending agency for the perform TOTAL. ELECTRIC FEE
Zanre ofthe work which this permit b issued(Sec.3097,CIv.C) ,
02 Lender.N.me PLUMBING FEE
Lj_ H Lender'.Addomat QZ . MECHANICAL PERMIT FEE
MECHANICAL FEE
O W Iredilythatl love read thbappllotlon and statethatthe above information -
Is correct.I agree to comply with all city and county ordinance and pate laws PERMIT ISSUANCE FEES PAID:
} IL relating to building construction,and herebyauthorucrepresentativoo!this
f•' fA city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECIL
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,M CFM)
SUBTOTAL:
ag mj7—
AIR HANDLING UM'f(OVER 10,000CIM) CONSTRUCTION TAX
Signatu re of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOUS MATERIALS DI SCLOSU RE
Will the appliea rat or future building occupant store or ha rad le hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
material as defined by the Cupertino Munidpal Code,Chapter 9.1 2,and the
Health and Safety Code Section25532(a)? HEATING UNIT(OVER 100,000 BTI!) TOTAL: t
❑ YesNo
Will the applicants future building occupant use equipment or devices- VENTILATION FAN(SINGLE RESID) ISS�lD DATE
which emit havardous air conte mirunta as deRrud by the Bay Area Nr �/tN��
Quality Management DiQQst�ri�ct? BOfLER-COMP(3HP OR 100,000 BTU) 1,
4No
have read the h.afdoous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Juil 2 v jggU
the Glife.0 Hiealth&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. Q��sa ss�/s���1p1{�..aa
respo[nsibility to notify the occupant of the requirements which must be met W YYAo4Wt1V
pe�ri■■rred9tr rcc& mficateof Occupancy. 7 F���11V pLpp/1
Owner hmired agent ^Date �� ISSUEDBY:Ij�W`""
TOTAL:
OFFICE COPY 1