20027APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
eulldin Project Identlfkatlon
PER\IT NO.
Building Address:
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rcr ame:
CITY OF CUPERTINO-BUILDIJG DIVISION
APPLICATION / PERMIT
BUIIDINGQ.BCTRICALPLUMBINGMFLHAMCAL
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CATEGORY CONTROL
Architect/ gircem Ids No:
Q ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE c
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lkmud underprovidana of CTupter9 (mmmim
Ingwith Section 7000)of DtvWm3ofthe Bustnessand ProfessionsCode,and my
APPLIANCES ENTAL
I-JJUB
� 1411'1""
Ilnnse b lo full dkfeR Iej � 5B
Ekes
PANELS Ti
Oahe ontndor
AIiCH11ECTS DECLARATIONpublicemu
/t�V'"�•
QVrR I
VFR I(D6
SQ. FT. FLOOR AREA
$/5Q.FT.
Iunderaad my Etas shall be used as public re coda
NS EU
Liceed Professional
s
L
OWNER -BUILDER DECLARATION
I hereby affirm that I am rzempt from the Contndori Llase Law (m the
O ,NST.
foL'owing realm. urectim 76715, Buelnes and liofmbna Cade: My dry or
muntywhkhmqur apermitwms Malter,Improve,de to h,orrepalr
anyatr Mmprbrtolbbuar ,aleorequ Lheapph=tfwsuchpemdtto
�yI
filo a signed statement that he is Iterowd pursuant to the provisions of the
S1ypU,gNG L
Contrmemem License law(Chapter 9(commencing with Section 7000) of Divi-
stop 3ofthe Beale. and Pro/ealos Code) or that he b exempt them mmard
VALUATION
the basis for the alleged eumptbn. Any violation of Sedlon 7015 by any
applicant form permit subjects the applicant to a civil penalty d not more than
m
OIITLELFSWI
RESID SQ -Fr.
flu hundred dollars WW.NEW
1, as owner of the property, or my employees with wage as their Bole
STORIED
TYPE CONSTRUCTION
�
oampenudon,will dothe work, and thestmelun Is not!Mended or offered for
ale (See.70141, Bualrmsma sod Prdea mu Code: The Coomadah Limns Law
don not apply to an oweer of property who builds or Improvn thereon, and
who doessuaworkhareelf orthrough Msown employees, provided thatmch
Improvements are ret Intended oroffered forsale. If, however, the building or
TOTAL
OCC. GROUP
RES. UNITS
Improvement bsold wlthirmayearofmmpletbRtheowner-0ullderwW 1uw
t rden of proving that he did not bund or improve for purpose ofsade.).
1 as sumer of the property, am exeluelvely contracting with license
mntndn oto construct the pmjrct (See 7DK Business Preafess loCode:
QTY, PLUMBIr4GPERMIT FEE
ZONE
FLOODAPN
I'QtMIT ISSUANCE
The Conteactor's Licems, law does ata apply to an owner d property who
builds or Improves themon, ad who mMram fee such xoJects with a
ry➢tT+dm(.) BoaruM permeant to the Cmunde/s Limns Law.
U I am exempt order Sec B & P C for this meson
ALTER-DRAI194 VENT- WATER(EN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT 1
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Insure, a a
mrtificanamworlen'Comperoatlon Ins rot oe arertifldcopythereef5ec.
3800, Lab C.jQ�
1J —�Q— �
FIX7VRES PER TRAP
SCHOOLTAX Y_ N_
gpCpEPT I
GAS EA. SYSTEM -1 IJCI OUTLETS
PARK FEE Y_ N_
RECEIPT 0
GAS. EA. SYSTFM.OVER A (EA)
CoKH,kJ'•_W
I copy b hereby furnied. �T �'�s
Nd copy Is Toed with the dty Ispection division.
BUILUINCDIVIBIONFEFS
GRFAse/llrollsrRL WASTE 1NT"Fxc EPTOR
PLANCHECKFEE
GRIASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCESEWER.SANITARY
Rhus seellon need nd he cnnpldd If thepemdt b (more hundicd doaan
Date Recei t#
STORM EA NMA•",,
WATER HEATER w/vENr/¢LcrR
ENERGY FEE Y N
(910()mles.)
Icertlfytia les aperformannofthew kforwNchthbpem isb d,
WATER SYS1PA1/7RFA77N'G
I shall out employ any person to any runner su as to become subject to the
worker: Camperwtbo Ewa of California. Date
PAID
Applicant
.NOTICE TO APPLICANT: R, after mbeg this Cam late of Exemption, you
NEW RE4DENTIAL PLMB. SOFT.
Date Remi t#
TOTAL
should became meb}ct to the W.d en' CorepesaHon provisions of the Lbor
Code, yne rwsl fonhwfth compty with such provbbs or this permit "I be
BUILDING FEE
deemed revalued.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby.fOrmthatthereba cosrectim Lerdingagencyforthepedom-
arm of the wort for which thio permit b taeued (Sec 3D97, CN.C.)
lendero Name
Lender',Add.
I mrtifyth.tl luvenedthle appllutbnad staethm theabove Wormtlw
bcormct. Iagmtocomplywithallchyad coomyordlnancesand statelaws
TOTAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE'
MECHANICAL FEE
PERMIT LSSUANCE
FEES PAID:
relating to building cormtuctlec, and herby authorise representatives of this
cftybenterupon the above-mentbred property for Wpectlon purposes.
(We) agree to ave, Indemnify an d keep harmless the Chy of Cupertino
bwtln, }rdgmen oaet,andexpensessahkhmyie. ay..m
• ad City oeeee ce ftheip" ng oftMs a
ALIIERORADDTOMECH.
Date Reeei t#
AIR HANDLING UNIT ITO 10,000 CFM)
SUBTOTAL.:
AIR HANDLING UNIT (OVER 10,000CESo
CONSTRUCIION TAX
S stun of Apphant Con ndr: I YDto
D(IlAusr HOOD(W/DUCD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO R
HEATING UNIT (10 IOD,010 BTU)
Date Reeel t#
Wllltheappliuntorfuturebullding.part store a Is ha:ardmu
material s delsd by the Cupertino MuNdpal Code,C 9.17, and the
Heahh and Safety Code SMW, 75532(.)7
FI yea No
Wal the aPplfantm ture building omupant use equipment or devim
HEATING UNgT(OVER 100,00) BM
OTAL:
L
Jl
VENTILATION FAN (SINGLE RESID)
I •DATE
which emit haardmu air contamiranta as defired by the Bay Area Air
Ifty Management Dbtrldi
shave
LanJ ) D 199J3J
BOII.ER-ODMP OFT' OR 100,0W BTU)
Yn 1Q�No
MAR N
BOILER-CVNP(OVER IW," BTU)
read the b...a mtedab requirements underChapter&95 of
the Callnmla Health & SafrtyCode, Sectbs 25505, 25573 and 2553!. I
understand that it the building don not arrtntly have a teem that It is my
responsibility to notify the o pant of the requirements which must be met
Lha,�,y{(;IInPI}11M
NEW RESIDENTIAL MECH. SQ.FT
prior to isuarco of. Certifeate of Oavpa ocy.
ISSUED
I
Owner or authorized agent Date
TOTAL
OFFICE COPY