20497 ANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification .. PEItIAIT NO.
"dog 20497
M
one. A A p
O �Q /j/ cl / CITY OF CUPERTINO-BUILDING DIVISION A I—qt
.airs rp .mn .Lie,No: APPLICATION'/ PERMIT
1 Y BUILDINGEL TRICALPLUMBING-MECFIANICAL CATEGORY CONTROL p
Architect/Engineer. - Lie No:
— — //a� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: Z r`(/ �/J' PERMITISSUANCE ❑ ❑ ❑
LICF.NSEDC TRACTOR'SDECLARATION
I hereby affirm that i am licensed under provision of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOBDESCRB'1TON
ingwlthse t°n7000)of DiWM.o 3ofthe BusinessandProfessi.nsCode,and my 9�krs-��
License
Is in fu8 force and effect. PANF]S t �v� L`�
Date Class Cont
Date Contractor
ARCHITECT'S DECLARATION 201-IODOAMP$
O
Z I understand my plans shall be used as public records. OVERIOWAMPS SQ.FT.FLOOR AREA 8/SQ.FT.
pO+ cO
E Z tj Licensed Professional I SIGNS ELECTRIC) A
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ LSC v
t, Thereby a(B rmthat lam exempt from the Contractorb License law for the -
7.op following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z F TEMP.METER OR L ST.
.county which requires a permit to construct,alter,improve,dennlbh,orre.
anystructure prlorto its issuance,aLso requ nslheappliant for such permit to POWER DEVICES
O file a signed statement that he is licensed pursuant to the provbiom of the
�a Contactor'sLicense Law(Chapter 9(commencing with Section 7000)o(Divi- SWIMMING IDOL ELECTRIC
sion3ofthe Buamugimd ProfemeorsCode)or that he Is exempt therefrom and VALUATION
the
Y.' the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTUFES
Q applicantfora FerMt subjectsthe applicant to a civil penalty of net monethan
oflyEbandred dollars($500). NEW RESIDENTIAL FT ECTR SQ Fl.
I as owner of the property,or my employees with wages as their sole STOW ES TYPE CONSTRUCTION
In(Sec.
wllldothe work and thestructure is not Intended or offered for
Ole(Sec.7094,Business and Professions Code:The Contractors License Taw
does not apply to an owner of property who builds or improves thereon,and OCC.GROIIIs RES,UNITS
who does such work himselforthrwgh his own employees,provided that such
Improvements are not Intended oroffered formic.If,however,thebuilding or TOTAL:
improvement bsold withinoneyearofcompletiogtMe ner-budderwill have
the_I,urdea of proving that he did net Wild or improve for purposeotsaled. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with licensed
contractor to construct the project(Sec.7014,Business and Profession Code: PERMIT ISSUANCE CN
The C.ntnctorb Lirense law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pkojects with a FEE SUMMARY
ft aLtor(e)Rrensed pursuant to the Contractor's License Law. gAIX FLAW PROTECT.DEVICE
I am exempt under Sec. B &P C for this reason
DRAINS.FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
Owner Date RECE1P`1'p
WORKMAN COMPENSATION DECLARATION HI(TVRES PER TRAP SCHOOLTAX Y_ N
❑I hereby a((Irm that I have a rertlfiate of consent to self-Insure,ora RECEIPT M
crmficat2 of Worker'Compensationlwurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFM . Y N
3800,lab C.) RECD[ p
ny
Polity S p GAIIx.SYSTEM-OVER 4(EA)
- BUIL DING DIVISION FE CS
�a
certefiea copy Is hereby famished. GREASE/INDUSTRL WASE INTERCEPTOR PLANCHECKFEE
❑Ceri ied copy b filed with the city Inpectl.n division.
CERTIFICATE OF INEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAM.I.gRY-STORM Eq.2(IOFI.. Date RCCei I#
(rhes section need not be completed lithe permit b for oro hundred dollars
($1 W)or less.) WATER HEATER W/VENT'/ELECTR ENERGY FEE Y_ N_
I cxrtifythat in the performs.of thewwk f.rwhlch this permt b bored,
I shall not employ any proven In any manner so as to become subject to the WATTR SYSITM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQFT. Date RCCei t#
Z O NOTICETO APPLICANT:ILaRer making thb Certificate.!Exemption,you
should become subject to the Worker'Compenation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions orthis permit shall W
W >. deemed rewked. BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a � IMicbyafflrIn that there is a construction lending agency for the perform 1(J. ELECTRIC FEE
0 Z imen of work for which this bsv
permit ised(Sec 3097,Civ.CJ
TOTAL: l•'`
02 Tender's Name PLUMBING FEE
LL I—• [enders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I rertBythatl have read thisappliabo
tionand statethat theave form.tton
1 is corms.7 agree to comply with all city and county ordinances and nate laws PERMTTLSWANCE FEES PAID:
>. mlating tobulldeng commecteon,and hembyauthorbm representativeso!this
(— N city to enter upon the above,mentioned property for inpectbn Purpose. ALTERORADDTOMETH.
Z (We)agree to save,Indemnify n d keep h.rMew the City of Cupertino Date Receipt#
V againstlbbllite,s,iLl, nts,co nd expenses whechmayenanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against. I. sequin l the granting of this permit
.4 sa ` _ J- AIR HANDLING UNIT(OVER IO,MC[M) CONSTRUCTION TAX
gnal,OWrAq . rarer Date EXHAUST HOOD(W/DUCT)• CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the apple n r future building occupant store or ha nd le hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
material as deli y the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Satcty We Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes
Will the applicant M No
rfuture building occupant use equipment or devices VFNTTLATION FAN(SINGLE RESID) ISSUA&ATE
which emit havardous air contaminants as defined by the Bay Area Air lJ
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4ae ��° requ Chapter ,Ilii o11y90
have lead the Fav materials ircmenb under CFa 6.95 of BOR-E2COMP(OVFR 100,000 BTU[
the Caleforela Health&Safety Co ie,Section 25505,25533 and 25539. 1
understand that if the building does not currently have.tenant,that it is my NEW RESIDENTIALMECH. SQ.FT. '
responsibility to notify theoccupant ofthe requiremenbwhich must be met px s� ps..�p
prior to issuance ora Certificate of Occupancy. 'City.
of cu,I�!.4�rw
Owner or authodeed agent Date ISSUED BY VLu�Y'rhi�-/u.V•*-'-'C-1
TOTAL:
OFFICE COPY