20103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project Identification PI7tSET NO.
Building Address: 20103
2/ 3 `116 �, � c
"07 e: A .A
BUILDING DIVISION17Ze , CITYOFCUPERTINO
cnntraaer,Na Lm.No: APPLICATION I PERMIT b
r CK (4 aT Lei_ BL7LDIVGELECTRICALPLUNBING.NECHA\TCAL CATEGORY CONTROL X
Architect/Engineer !! LI No
e lC ` •"�'� QTY v'' Ae ELECTRIC PERMIT 'pFEE'tj } � BUILDING PERMIT INFO r
Address: 7> • StLCH
PERMETISSUANCE 2,� ❑ El -
LICENSF,D CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter9(mmmmc APPLIANCES-RESIDENTIAL Q JOB DESCRETION
Ingwfth SmBion700e)of D,v6ion3 mAhe BusinmsandProlnsion,Code,and my
license is in full force and died. PANELS nom}
Linens¢Clam LIC.N f--F�
Date Contractor 1 1 1
ARCHITECTS DECLARATION 201.10MA.MPS
i O Z I understand my plan shall be used as public r¢cords. OVER I W0 AMPS I SQ.FI.FLOOR AREA S/SQ.FT.
O
C d 6 Licensed Profeseunud SIGNS ELECTRICAL
<<c`'1�. OWNER-BUILDER DECLARATION 57'ECIA CL MLSC
in Iherebyaffirm that l am exempt from the Contractor's License Law for the
O_9 following mason.(Section 7071.5,Business and Professions Code:Any dry or TEMP OR 6 N
',n=_n countywhichrequireeapermlttocomtmd,alter,impmve,dennlish,ormpair
anystm=mpdortoist ance,alsoequirestheappH¢ntfor,uchperndtto POWF�CFS
file a signed statement that he is B¢nsed punuant to the provision,of the
Contractor's License Low(Chapter 9(commending with Section 7000)of Divi- SWIM NG LELE
OS sion3ofthe Businemand ProfcmiamCMd )orthathe6exempttherefmmand VALUATION
e — the basis for the alleged exemption. Any violation of Section 70115 by any
i' OUTLETS- TCF3ESFTX(URFS
applicant for a permit subject,the applicant to a civil penalty of rad more than
,$
five hundred dollars(SW. NEW RESIDENTIAL ELECTR SQ.FC. STORIES TYPECONSIRUCTION
n— I,as her of the property,or my employ.with wage,a they,ole
CZ compensaHon,will do the work d
and thestruure is not intended or offered for
❑ sale(Sec 70K Buslnessand Professions Code:The Contradoes License Uw
does not apply to an owner of property who Wilds or improves thereon,and OCC.GRO[II' RES.U\TTS
-- who does such work himself or through his own employees,provided that such
improvements are not intended oroftereci forsale.If,however,thebuiiding or TOTAL:
Improoemcnt issold within oneyearofcompletiun,theowner-budderwill haveI
ttc�urden of proving that he did net WRd or bnpeove for purpose ofsale.L t:a:-;spLCIMBING'PERMIT:?3 f ..;FEE;i'i FLOOD WNE APN
I,as owner of the property,am exclusively contracting with licensedrontradera to construct the project(Sec.7054 Business and Professions Code: PERMIT ISSUANCEThe Contractor,License Uw don not apply to an owner d property whoALTER-DRAIN k VENT-WATER(EA)
Wilds or improves thereon, and who contrails for such pi jecn with a e-,>.Cse'..,.iti •,y-a
yy5�actor(,)licensed punuant to the Contractor,Liwnse Law. —,x�}..s ga;,.�FEE_SUMMARY `+, 2< �,yHr
LJ BACK FLAW PROTECT
I am exempt under Sec- B de P C for this reason .DEVICEOUTSIDE FE
Owner Date DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y_ N
RECEIPT a
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCILOOLTA% Y_ N_
hereby affirm that 1 have a¢rtifiate of consem to se141nsure,or RECET E s
¢r
1500,UbC.)te .Workeni Compemadan Wuran¢ora¢nilled ropythereaf(Sec. 1 GAS PEVI
EA.SYS -i L\ PARK FEE Y CAOUTLM ,,sir N
• 2,c7s RECEIPT
?cliry p CAS EA.SYSTEM-0VFR 6(FA)
Cem any BUILDING DIVISION FEES
Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Cenif ed copy 6(sled with the dry inspection division.
CERTIFICATE OF EXEM MON FROM WO RKERS' GREASE TRAP PAID
.MET. Dale
COMPENSATION INSURANCE SEWER-SAMEARY-STORM EA
(This sedion need n¢W completed lithe permit is for one hundred dollars -
Remi t#
(s1(0)onem.) WA .� / / .� ENERGY FEE Y_ N_
I certitythat inthe performance ofthe work forwhic�Ms W sued,
I sM1all not employ any person in any manner so m to=Fb'ject to the r WrATQt - NG
Workers Compensation Uws of California.Date PAID
Zz Z Applicant i 1 TNUdY �SQ�. Date Remi t#
O NOTICETOAPPLICANT:IQaftermaWngthb Certl(lote of E�cmptim,yoy J
should become subject to the Worke s''Compeneauon prov6ionfef the UW r TOTAL:
F (/) Code,you most forthwith comply with such provision,or this pemdt hall be 13 1 Vu BUILDINGFEE
Wj domed revoked. Des 1 C
Fm CONSTRUCTION LENDING AGD,lC:y SEISMIC FEE
d Iherebyaf0rm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE L
7 Z anceaftheworkforwMchthbpermitis ed(Sec.3097,Civ.C.)
V O lender,Name _ PLUMBING FEE M
Lender's Address QTY";` MECFIANICAL`.PERIv1IT 5 "�'FEEF;
O W I mntfythatl have read th6appli¢tionand statethanheabove information MECHANICAL FEE
correct.l agreeto comply with all city and merry ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N elating to building mectrodion,and hereby authorize representatives of this
Z Coyne enter upon the above-mentioned property for inspection purpose,. ALTER OR ADD TO MECH.
(We)agree to save,ind ertmily an it keep harmless the City of Cu pen me Date Receipt#
L.) against liabilities,pdgments,mks and expenses which may in any way accrue AIRHANDLINGUMT(TO10,"CM SUBTOTAL:
against said City in mosequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNH(OVER 10,IX)0 C[M)
Signture of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica nt orfoNre bu thing,.pant store or hand le hazardou, HEATING UNIT CIO 100,000 BTU) D e RMCI t#
material as defined by the Cupertino Mu nidpah Cade,Chapter 9.1 2,and the
I ealth and Safety Code Soction 25532(a)l HPATING UNIT(OVER 100,000 BTU)
❑ Ye, N No VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
Willthe hamedotorfuroreminants.,opineuse the equipment devices
which emit hagem nt is contamieanu as defined by the Bay Arca Air
Quality Management District? BOfLFR-COMP DFm OR 100,003 BTU)
Yn No
have read the M1aaa ons mueda6 requlren+enn under Chapter 6.95 of BORER-COMP(OVQt 100,000 OTU7
the GIllomo-leallh&H fety Code,Sediom25505,2-5533and2MM I 4117 of�UnLa/�' (I
•understand that if the building does not currently have a tenant,that it(smy \E'WRESIDENTIALMECIi. SQ.FT. '
repo ibility to rad Jy the occupant of the requvemenb which must be met e A ^
prior oissuan e4 ifiat of pan `�" 1.P
Pv or authorized agen Date TOTAL: ISSUEDBY: `+' Y t/ "'•-yL
OFFICE COPY