19762APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
630 vl
Lle. N.
Addm/C� / � /1r//fj/(
( LICENSED CONTR TACTORS DECLARATION
I hereby affirm that 1 am Bernard under provisions of Chaptar9 (comm,
ingwithS ktr7000)of DM9.3oft/he—BausiinesssimclPmfmWcauCode, and
Lico.nse Clam B fo an Liicf.I T Lfo
Dat,�Contractor
AKCHITECPS DECLARATION
I understand my plana shall be, o•.d an public nn ud>
Licensed Prof®tonal
OWNER -BUILDER N
DECLARATIO
I herebyaffi mthmoe
at I ampt fromthe Contrador's Losse lawfori
following mown. (Section 70315, Bu.I.. and Prc feaWna Code Any city
he is deensed pursuant to
don3 of the Sudneas and Prafeasbna Code) orthat he b eampt thenfmmand
the bub for the dleged ax rrptlon. Any WdatIoo of SMIen 70315 by any
appBant fora permit aubje tbaappll t to a elvll pesky d not mom than
five hundred dollars (5500).
❑ I, an owner of the property, or my employees with wag. u their sole
campeneatbn,willdothe work, andtht.ImQure b not Infrared or offered for
ale 6ce 70K Bu.ireu and Iho(estoru Code: The CoMrsdots U.. law
does not apply to an owner of property who buI1N or Improves thereon, and
who door such work himself or through his own employees, provided that such
Improveme ancotIntendedorofferedforsale. If, however, the building or
Impmvc mbsold Mthinomyearofcampletbn,theownrn-bdldmwWhave
1 oienofprovingthathedkl mrcbuildorimproveforpurpoeeafsale.).
Lj 1, as owner of the property, am eschuawrly contrvdtng with licensed
oontradma to mrmtrud the project (Sec 70K Buslnna and professional Cod,.
The Contnoore Lkerue Law does nmt apply to an owner of property who
Wil" or Improsv tit., and who compos for such plokcb with a
onntraetee(s) Boenad purruant to the Contradd. License Law.
1_ I I am exempt uoder Sec B 4 P C for this renin
Owner Dale
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a .rHBate d eviarnt to self -Ion, or .
renNa4 of Workm' Comperwtlon Ircuan. a • e.n fled copytheoof tSrn.
38001 Lab CJ
Pdicy a
ry
IICcrtlRedd copy In hereby fuMshed.
Q CcrtNed copy Is filed with the city, WpMbn division.
CERTIFICATE OF EX1,MPTION FROM WORKERS
COMPENISATION INSURANCE
(fhbsenbn need not tr completed Bthe perMt is fmrma hundred dollars
5 W)aluJ
1.rtoy slut lythe person 1. of the work for whichee ptmdtIs cboth,
I stall no employ any peau In any menner at u to become obfni to the
Waken'Campewlbnlaw. of Glifmmh. Date
should become subject to the Workars' Cemperuatlun povbloro of the Labor
Code, you moat forthwith comply with ouch provbbnu orthb permit shall be
deamod rewkrd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then b a conawMon lending agency ter the perform-
ance of the work for wheh this permit Is Lssred 5ee 3091, Cl, Q
I.e dre. Name
Land &a Address
I.rtify thal have rod thio appliatbnand.tatethd theabave Information
bconed. Iagm Nromplyw aBdtyandcountyOrdbenmandsatelaw.
ntadrig tbuildingcoadacw ion, and prrpauthorimrectlu.p rp.o.this
dtyWenterupontheabove-mentbnedProprtyfor thaCftpfCuper
(We) agree t..,, Indemnify and keep wh1eh the City of Cupertino
ago Cat llnbWtl.,Ndgmema, �e and caperma wheh may Nany way accrue
ago dChyl onnsequ (<Ofth granting Mthispemdt.
gwtvmof Ap ,comm Date
Widths
N RI30U5 MATERIALS DISCLOSURE
Allam the uperti uMunidplCode, Chapter 9. h, and the
material as danvd by the euperti 5 Mu Ntlpal code, Chapter 9.11, and the
Hallhea Sdety Cade5ecilon 25531(a)t
❑ Y. t] No
WE] the applicant or bNn building aauputuse equipment .devices
which eMt havrdmus ab rm�landnaMe as deRmd by the Bay Area Alr
Quality hUrugcrrcnt D1,,trlct7
4Yen ❑ No
avereadtheba�..mteab gbmnhunderC1,aperG95of
the Cu Bfomla He"h h Safety COde, SedbM 15505,15533 and 75534. I
understand that If the budding does not currently have. ten.L that it Is my
responsibility to natlfy the o pant of the requtmoentawhieh trust be met
prlor to Isuance d a Certtfota of Occupancy.
Igen Data
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BLMXq NGE. VCTRICAL,MUMBING-MECHA NICAL
ELECTRIC PERMIT
_Tz"77M
PLUMBING PERMIT
PERMIT 153UANCE
ALTER -DRAIN 4 VENT- WATER MA)
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CDND.
F'DCRIRES PER TRAP
GAS EA. SYST9A-1 ♦NCI OUILEIS
GAS EA. SYSIFM-OVER I (FA)
GREASE/D=SIRL WASTE INTFRCEYIOR
GREASE TRAP
SEWERSAMTARY-STORM EA. 201FT.
WATER HEATER W/VENT/ELFCIR
WATER SYSIFM/TRFATIx
NEWRE5IDENTIALPLMB.
TOTAL:
MECHANICAL PERMIT
ALTER OR ADD TO MEGIL
AIR HANDLING UNTf (TO 10,ODO CFM)
AIR HANDLING UNIT (OVER 10,"CIM)
FJ(FU=HOOD (W/DUI: D
HFATING UNIT (TO 100,000 BTT)
HEATING UNTT (OVER 100,00) BTU)
VFN'(TLATION FAN 6INGLE RFSID)
BOB ODMP OFTOR 100,000 BTU)
BOIIXR COMP (OVER 100,OOD BTT)
NEW RM DENTAL MECH. SQ.FT
OFFICE COPY
FEE
FEE
"Do
00
rFR,wTNo.
19762
17 49
CATEGORY
CONTROL♦
BUILDING PERMIT INFO
V� ❑ ❑ ❑
OB/IDF_9C11R_IPIIIO�Nt-t
L �
SQ. Ff. FLOOR AREA $/SQ. FT.
s -D 7Y-�L
VALUATION
O
33,7/ �f
STOW
TYPECONSTRtICITON
I
Y
OCC.GKQUI,
RES
R— 3
T
FLOOD ZONE
APN
36S'LC-a
FEE SUMMARY
SANITARY Y_ N_ ,
RFC=
SCHOOLTAX Y_ N
RECFIP g
PARR FEE - Y N
RECE9rf a
BUILDING DIVISION FEES
PLANCHECK FEE QT 71
PAID 1
Date Rcoef t#
ENERGY FEE Y _ N _ Sp, /D
PAID S- Cyd
Date Rcoel t#
TOTAL:
5UILDING EEE IV • S -V
SEISMIC FEE . 38
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE - D
FEI!M��yy�
Date Recti t#
SUBTOTAL:
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Date Recei t#
TOTAL:
ISPJA6M DATE
City of runaRrifrio
1 .
~' 1 b VL V
ISSUED BY: