20026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification I'PJtMII'NO.
Building Address: 20026/ U 7
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C,71"J CITY OF CUPERTINO-BUILDING DIVISION
CatsName: y LeNo: APPLICATION I PERMIT
a�- PQ � / Z BUILDINGELECTRICALPLUMBING-MECIiAMCAL CATEGORY CONTROL
Architect/En Lie Nix
ELECTRIC PERMIT : - FEE BUILDING PERMIT INFO
- ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I
firm,hit
lam licensed under provuiovof Chapter9(mmmenc- APPLIANCESAESIDGhTIAL ]OB DEXRBTION
li Melet
t fon7(p0)ol defffect Nthe Buslnessand ProlessionaCode,and my
limnse Is in(uB f and dies. PANFIS
Lianse Clan Lies 7 YZ
Date
Caruractor ' I>"•�
ARCHITE LAR ni �j 00 AMI5
a0 Z. 7 understand my plan ia8 be used v public rcmNs OVEROVER illi AMPS SQ.IT.FLOOR AREA 8/SQ.FI.
z Ivi[) Licensed Professional SIGNSELECTRICAL
<y OWNER-BUILDER DECLARATION
0, SPECIAL CIRCNT/MLX
'-�_ I herebyaflirmthat l am exempt froenthe Contractor's LlmnseLawforthe
following reason.fSection 7m15,Business and Professions Code:Any dry or
muntywhichrequiresapermittocovtrod,alter,improve,demolkh,orrcpair TEMP.METIER OR POLE SI.
H jot; anystm=mpdartnitetavuance,almrequimstheapplimntforsuch pernetto
.�j file a signed statement that he Is limned pursuant to the provision of the (OWER DEVICES
0- Contractors Licevelaw(Ch er9(commenadn with SecHon7000)of Divi- VALUATION
c' Pt B SWIMNUNG POOL ELECTRI
'0 5 the basis for
Business and ProfessionC Any
orthat violation f exempt therefrom and
N y.'_ the basis for the alleged exemption.p Any violation a(naaty o 70)15 re any OUILETSSWITCHESFIX UR M//rs'���� 00
_per applicant fon permit subjMsmeapplkanuoadvil penalty of not mare than �000x
five hundred dollars(550(1).
I,as owner of the property, NEW RESI TIAL EL
r^^ STORIES TYPE CONSIRUCTIOh'
:2� O Ho willdothe work,and
my employees eswithwdedor offered
dfo
peva n, kaogue.structure, e,Contnot actor or o!l Law
a�O sale(Sec 7044,Busimas and I'ro(esslov Code:The ContradaYs Lireve law
_�R does net apply to an owner of property who builds or improves thereon,and OCC GROUP RFS.UNIT'S
who does such work himself or through his own employees,provided that such
improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement usold within oneyearofcomplction,the owner-Wilder will
have _
th,SVNen of preving that he did not bund or brpmo,e for purpose ofsala. ING'P T• F1:E"?" pLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMITI ANCE '1 r.rA
contractors to construct the project(Sec 9044,Business and Profession Code: Y1-MJ
The Contractor's License Law does not apply to ao owner of property who ALTERDRAIN4 TER
Wada or Improves thereon,ancontracts -
contrafor such puppets with a `FEE.SDMMAAY'` '
o6act.r.)limned pursuant to the Contractor's License Law. BAIX FLOW PROTECT. E'VICE
LII am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N—
Owner DMe RECEE'T M
WORKMANCOMPENSATIONDECLARATIONFIXTUItFS PER TRAP COp�UOL I" Y— N
•" ❑f hereby affirm that I have a artifiate of consent to se8-Inv¢,ora Vas ctif
relab C.) RECEIPT
e
lateofWorker%CompevaHonlvuranre ora rertlfkd ropy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
ftif
Poli
Comry n GAS F.A.SYSITM-OVFR4 MA) BUILDING
Y BUILDING DI VISIOS FRES
Certified copy is hereBled with
Due city
d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy u(cladwith the city Inspection division.
CERTIFICATE OF EXET1PION FROM WORKERS' GREASETRAP PAID
Cm W dor
COMPENSATION'INSURANCEMe SEWER-SANITARY-STORM EA.200FT. Date ReceI t#
Rhissettbn need fiat W complded If the permit u for one hundred dollars
(SIM)orless.) WATER HEATER W/VENT,/ELFCTR ENERGYFEE Y N
I dertify that In the performance of the work forwhich this permits issued, —
I shag nm employ any Person In any manner w
as to become abject to the WATER S,ST�/flREATING
Workem'Compensation Lnnof Califomu.Date PAID
Z Applicant SQFr. Date Recei t#
_ O NOTICE TO APPLICANT:If,raker making this Certificate of Exemption,you NEWRE IDENT1ALPLMB.
should become subject to the Workers'Compensation Provisions of the Labor TOTAL:
N Code,you mu at forthwith comply with suchpmvufovpermit L UI DINCE t,Cm> damed revoked.
L CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there u a mntrudion lending agency for the perform TOTAL: W ELECTRIC FEE
ana of the work far which this permit u(wed(Sec 3097,Civ.C.) t
O Le.de"I""" PLUMBING FEE
.L Lender's Addreaa QTY. `e- MECHANICAL.PERMIT, ` .FEE MECHANICAL FIE
D W Icenily that l have read this application a M state that the above Information
a uderren.l agree to camplywlthail cityand coamy.ndnances and state laws PERMIT ISSUANCE FEE-PAID-
relating tobullding mvtrudi.a.mi hereby authorize repmeentativesofthu
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(W4,agree to save,indemnify an d kapM
haress Date Reeeit#
P the City of Cupertino
against liabilities,Judgments,consand expenses which may in anywayamue AIRHANDUNGUhTI(T0I0,"CFM) SUBTOTAL:
against said City in conswryena of the granting d thls permit
AIR HANDLING UNIT(OVER I0000CFxf) CONSTRUCTION TAX
Signature of ApplHAZARDOUSor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutnre building occupant storeorhandle hazardous HEATING UNIT(TO 100,[00 BTU) Date Recci t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 75i32(a)7 HEATING UNIT(OVER 100,000 BTU)
n Yes M No TOTAL•
Willtheappliant or furnoWilding occupant use equipment ordevuens VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air _
F Quality Management Dutrfctl BOILER-COMP OH('OR 100,0(0 BTU)
�. I—I Yes I-1 No
`Yh %dthehazar7i'msmateriauaquime ntsunderChapter6.95of BOILER-COMP(OVERI W,000 BTU)
v
the Californu Health&Safety Code.Sections 25505,25533 and 25534. 1
understand that if the building does not currently have.tenant,that it is my NEWRE51DENTIALMECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be rat
prior to issuance of a Certificate ofOavpancy.
Owner or authorized agent Data TOTAL: ISSUED BY: ICJ C/IYIV`1\<1laJ,�C��'
OFFICE COPY