20121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prmjcd Identification - PEILWT NO.
Building Address: !, o 20121
wnere�TLa1cr,e: one: A A A
f3f'N , - CITY OF CUPERTINO-BUILDING DIVISION
cono-aRor'aN mem Lic.No: APPLICATION / PERMIT l
Architect/En nee \ BUILDING
-ELECTRICAIlPLUMB(NG-MEC}IAMCAL CATEGORY CONTROL#
g Lic.Na
-QTY - ELECTRICPERMIT- ,FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE ❑ ❑ F-1 LICENS EDCONTR under rDECLARATION
IM1th Sb ffirmthat lamlken3ofthe usinemslons°f Chapter9(mmmenc- AI'f'LIANCESRFSIDENfIAl' JOB DFSCRR'TION
InnnseI In fon force
effeon3o(the8usinessand Professions Cade,and rtry
license b In s force and c.N PANELSLice (
Date Class Contractor
Date Contractor
ARCHITECPS DECLARATION 201-IOODAM
�2 I understand my plans shall be used as public records. OVER 1000 AM SQ.Fr.FLOOR AREA --i/--Q.Fr-
00
r
qq�-+ O
k N U Licensed Professional SIGNSEL TRICAI.?.
�<<¢N OWNER-BUILDER DECLARATION SPECIALCIR LSC
71.., Z Iherebyaffirm that lam exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
O�i.. county which requlrusa permit to construct,alter,Improve,demoliah,or repair TFMP.MEfIIt L
anystrecome priortolts issuance,also requirestheapplicanl for such perMt to AVER DEQ
U Ole a signed statement that he b licensed pursuant to the provisions of the
�3wn Contractor§License Law(Chapter 9(comarencing with Section 7000)of Divi- N[GIPOOL E C
FO� slon 3 fthe Business and ProtesslomCode)orthat he V exempt therefromand VALUATION -
�.'S the basis for the alleged exemption. Any violation of Section 7071.5 by any ,/OUTL 7CFPES S/� 0a
applicant fora permit subjects the applicant to a civil penalty of not more than � .
P. five hundred dollars(S50G). NE DENHAL EL .IT.
Z< ❑I,as owner of the property,or my employees with wages as their sole r SfORIER - TYPE CONSTRUCTION
ompensationwBldotheworkandthestmct ml9notintendedor offendfor
` ❑ giIn(Sec 70 Business and Professlons Code:The Contracto/s License law
'j'3R does not apply to an owner of property who builds or improves thereon,and OCC.GROUP AES.UNTI5
who does suchwork himself or through his own employees,provided that such
improvements am not Intended oroffered for i ale.IL however,thebulldlog or TOTAL:
improverrcntis sold within oneyearofcompletion,the owner-bullderwill have
tlicjnudenofproving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L�L as owner of the property,am exclusively contracting with licensed ppRM17 ISSUANCE
contractor to construct the pmjed(Sec.70K Business and Professions Code:
The Contractors License Law does not apply to an owner M property who
Wilds or Improves thereon,and who contracts for such plojects with a ALTER-DRAIN,&VENT-WATER(EM
cctrlctor(s)licensed pursuant to the Contractor.License Law. FEE SUMMARY
L�I am exempt under Sec. B k P C for this region BACK FLAW PROTECT.DEVICE OUTSIDE FEES I
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT k
WORKMAN COMPENSATION DECLARATION FIXTURES PER•TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certlOate of consent to sel6insure,ora RECEIPT X
certiflate ofWorkere Comperuation lmurancemra certified copy thermf(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Ub C.)
Policy#rtGAS EA.SYSTEM-OVER4(EA)
URECEIPT#
CoDING DIV
ISION FEES
EClfed
copy is hereby furnished. GREASE/INDUSlRL WASTE INTERCEPTOR PLANCHECK FEE
❑Cenified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWFRSANRTARY-STORM EA.200Ff. Data Recei t#
(Hilssection aced not M completed If the permit E forone hundred dollars
($10))orlev.) WATER HEATER W/VENT/EI,ECTR ENERGY FEE Y N
I omilythat In the performance of the work for which this permit bsu
ised,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM./TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RES DENT Al'P MB. SQF. Date Remi tp
Z U NOUCETO APPLICANT:If,after makingthu CenBlcateot Exemption,you
should become subject the Worker'CompcMx1 km pieveat of the Labor TOTAL:
CC N Code,you must forthwith comply with such proWlons or this permit shall be BUILDING E L
W 9 deemed revoked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hemby affirm that there is a construction lending agency for the perform ELECTRIC FEE
7 Zante of the work for which this peroxt Is iswed(Sen.3097,Civ.C.) TOTAL:
U O (traders Name PLUMBING FEE
LL I— iendee.Addreaa QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
U I certifythat l have read th(sapplicationand statethat thealeve information
O W Isconed.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
}
W tr
relating to building construction,and hereby authorize representatives ofthis '
F N city to enter upon the above,menlboed property for inspection purposes. - ALTERORADDTOMECH.
Z (We)agree to give,indemnify an d keep harodess the City of Cupertino Date Date ReCeiptll
L) agabat liabilities,judgments,costs and expenses which may In anyway accrue AIR HANDLING UNIT TO 10,000 CFM) SUBTOTAL:
against said City in consequence of granting of this permit. CONSTRUCTION TAX
AIRHANDLINGulsTrovER1o,00ocE) -
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUC'H CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appliesrat or future building occupant store or is nd le hazardous HEATING UNIT(TO 100,000 BTU) Date RBCCI tis
material as defi red by the Cupertl no Mu nicipal Code,Chapter 9.12,and the - L�aT
I lealth and Safety Code Scaux,25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: l ��
❑Yes M No
Will the applicant orfuram building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS%I6NCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qa Pity Marogemard District? BOILER-COMP QHP OR l00,0D)BTU)
4 Yes [r APR a�s
have ala the Kezar mWc,Setions 2m05,25533 and 25534.
1 of BOILER-COMP 100,000 Blit)
the Uttandt Healtht if kSafety Code,Sections25505,ve a t nam,that it
Tj9
understand that if the building does not currently M1aveatenant that itbmy NEW RESIDENTIAL MECFi. SQ.IT � 0
responsibility to notify the occupant of the requirerrcnts which must be met OF
prior to Issuance of a Certificate of Occupaany. �i/Aft.
mIOTA L:
er or authorived agent Date ISSUEDBY: ^a'�W'f%aaaV17N�1-aVW
OFFICE COPY