20231 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project dentiaaation PERMIT NO.
BuBd Ing Add ress: Z 0 Z 31
IR191 VALOC) Kw
w�'ncj Cone: A A
V LO CITY OF CUPERTINO-BUILDING DIVISION ' (� i
Cmuraetm'shl. e:/ y� /��[ Lie.No: APPLICATION / PERMIT J l
i GLA-SSI CS 5 /•aJ�J BUILDINGELECTRICALPLUMBING-MECHAMCAL. CATEGORY CONTROL It
Architee/Ongi.can. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE El E] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commenc APPLIANCESRbilDENMI, JOB DESCRIPTION
'ngwilh Section M)of Divlsion3ofthe Busimmand Protesdone Code,and my
license is in and dfect. PANEIS
Data CbsL � Cot r 5 P•L�
Data i�–�e9 CHITS or �Q�
ARCHITECTS DECLARATION 201-1000 AMPS Kipi
�2 I understand my pure shall be used as public records OVEOVER 1000 AMPS SQ.FT.FLOOR AREA 4/SQ.FT.
qqP± O
E Z Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION ,
a�n SPECWLCIRCUIT/MLSC 1k y IA
7s' a (hereby affirm that l am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Pmlessims Code:Any city or
TEMP.METER RPOI.EI B .
rG
4p countywhlch requlresa permit tgrortstnrct,alterylmprove,demolish,orrepalr Fj.J.t anystmcture prior to its issuance,also requlresthe applicant lorcuch permit to ppW.ER DEVs
dk
fr` Cru'V file a signed statement that he Is licensed pursuant to the pmWiom f the
(Wj Ou, Contractor's Licenselaw(Chapter9(commencing with Section 7(1(10)oo(Dive SWIMMING TRIC
30 sion3ofthe Buslnessand Prof.k,.Code)mthat heiaexem therefroand VALUATION
v�� the basis for the alleged exemption. Any violation of Section m70315 by any OUTLETS-SWI
�y�� sppllanmore fora permit subjects the applicant to a civil penalty of not ore than
4 m j4 five hundred dollars($500). NEW RFSI DE141A,L ELZqA '41
.. ❑I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
zQ 94,compensation,will do the work and the structure b not Intended or offered gfor
F 0 sale(Sec.70Business and Professions Code:The Contractors License Law
j�$ does not apply town owner of property who builds or improves thereon,and OCG GROUP RES UNITS
whgdoessuchworkhimselforthrough Msownemployees,pr idedthatsuch
Improvements are not Intended oroffered forsale.If,however,thebulldingor TOTAL:
improvement lasold within oneyearofcompldion,theowner-buBderwill have
hrden of proving that he did not bu0d or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEB
eLI,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sec.7014,Business and Professions Code: PERMIT ISSUANCE
The Contractor's Lioness Law does nor apply to an owner of property,who
builds or Improves thereon,and who contracts for such p0ojects with a ALTER-DRAIN&VENT-WATER(EA) -
cont(actor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY,
ffI am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS-FLOOR,ROOF,ARTA,COND. SANITARY Y N_
Owner Date RECEIPT X
WORK MAN I have COMPENSATION DECLARATION FD(TIIRES PER TRAP SCHOOLTAX V N
(((
hereby arm h 9 at have a mrtiflate of consent ravel!-Nwre,ora RECEIPT X
A ate�o�f�Ws�or381 Lab C. �ke•rs C�o2mper tionllyns mncemamdifWmpythereof(Sec. GAS EA.SYSCEM-I WCAOUTLETS PARK FEE Y N -
RECEB X
Com any 1 1 =C-i?I GAS FA.SYSI'FM-OVER4(EAI .BUILDING DIVISION FEES
Ccrdfi copyisherebyfumished. GREASE/INC USTR 'WA [NITRCII'TOR i^ I CHECK FEE
Certified ropy is filed with the city inspection division. ../i. .. —9 u tl
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP �'' /1 IJ II `� �'P `'
COMPENSATION INSURANCE SEWER-SANITARY- "RM`EA 2IX1Ff. m-17 111 Date Recei 1#
(Thlssection need not be completed if the permit is forom hundred dollars
WATER HFA' W/VIC�1i,'eaecrR 'NERGY-•EE Y N
I certifythat in the performance of the work for which this Femur Issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TR EATING
Workers Compensationszwsof California. Date - PAID '.
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should beemine subject to the Workers Compensation provisions of the Labor TOTAL:
� ; Cade,you must forthwith comply with such provisions or this permit shall be BUILDINGFEE
W _ deemerevoked.
ked.
CONSTRUCTION LENDING AGL CY SEISMIC FEE L SO
CL
O Ihereby affirm that there is a construction lending agency for the perform- TOTAL: ELEC'T'RIC FEE
O anon oftheworklorwhichthbspermit6le dCec.3097,Civ.C.)
Lenders Name - PLUMBING FEE
LL r Lender'sAddress QTY: MECHANICAL PERMIT FEE
LL' andeffiatthe MECHANICALITE
O W ]mra.Ia agree to
complyread with aappliatiandcuntyordinancesabond information
S tiroect.building comply with andherey auntyordinanmsand gate laws PERMIT ISSUANCE FEES PAID:
.yt o enterng to u pont construction,ove- toned prop rty orize representatives of this
F W city(We)
ree to ave,he inve-mentlor N keep
Wpe Cit purposes. ALTER ORADD]'O MECH.
Z Date Receip[#
(Wel agree to ave, encs,m tts and keep harmieo the City of Cupertino
V
against liabilities,Judgments,mats and expenses which may In any wayaccrue AIR HANDLING UNIT(170 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit
.vrz]-v.NouNG un'1T(OVER lo,mocr•M) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous I rEATING UNIT(TO 100,000 BTU) Date ReceT t#
material as de0nedby the Cupertino Municipal Code,Chapter 9.I2,and the
Health and Safety Code icon 25532(a)? HEATING UMT(OVER IDg000 BTU) TOTAL: v7v
❑ yea WiBtheappilantg future building oecvpam use equi pment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdaus air contaminants as defined by the Bay Area Air
Quality Managcmem DimmIL
strid? BOER-COMP QHP OR 100,(100 BTU)
Tioe read the ha ft.asomaterials nequlrementsunder Chapter 6.95 of BOILER-COMP(OVER IW,OW
BTU)the California 1 [�
u ndersta ndhatif tthe bu 11 g dfety oes not currentlyhavea tena5,25533 nt tShat MM. ils my NEW RESIDENTIAL MECH.—SQ—FT. v� `yJ(�
responsibility to notify he ora pant of the requirements which must be met a,
prior to issuance of a Certificate of0 a . 'I/^�rf)eX
1-f� cyGQDC�
Owner or auth dud agent Date TOTAL: ISSUED BY:
OFFICE COPY
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