20276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
— Building Proj ct Identification PERMIT NO..
BWldin Address: 20276
'nen 1/•(F 9AAA one:
�rMTE
wR qP I j GR_
CITY OF CUPERTINO-BUILDING DIVISION ,�J
• c ° " (��S/ t/N APPLICATIONIPERMIT
BUILDING CATEGORY CONTROL p
At ci 'rarer. UG Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRAcF R'S DECLARATION
I hereby affirm that l am ecensed under pnwboona of Chapter 9(mmmenc. APPLIANCES-RESIDENTIAL JOB DFSC ON
IngwithSMion7000)of DlAsion3ofthe Busineasa dl- f. ssionsCodgandmy
licenseisinfu ic.# �xss PANELS PLv
Limnse Cl Ic.Nact.r �1Y 'Ul
Date Contractor
ARCHITECTSDECLARATION I01.1000A.MPS
70. I un erstand my plan shall be used as public records. OVER 1000 AMPS SQ.R.FLOOR AREA $/SQ.FT.
Licensed Pro rsxlo al SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION
Ihereby affirmthat lameaemptfmmthe Contractors License law for the SpECIALCIRCUIT/RISC
70 following reason.(Section 70315,Business and Profeasiona Code:Any city or
K7'f-u9 countywhich requires a permit to construct,alter,lmpmve,demolish,orrepair T'MP.M POLEINST
4gJ l< anystmoom,prior to its baance,also requinestheapplicant for such permit to
O0.U file a signed statement that W is licensed pursuant to the provisions of the POWER DEVI ES
Contractor's License Law(Chapter 9(mnvrencingwith5ectlon7DO(Dof Divi- SWIMMING ECTRI
f;�Oa sion 3 ofthe Business and P' esslonnCode)orthat he is exempt therefromand VALUATION
rj �"•..rt the basis for the alleged exemption. Any violation of Stolon 7W t,5 by any
�u of�C applicant fora permit subjects the applicant to a civil penalty a nal,marc than OUTLElSSWITC
five hundred delta.($500). NEW RF9DENTIALE TR
❑1,as owner of the property,or m y employees with wages as their sole RIES TYPE CONSTRUCTION
C,7�a compensation,wBldothe work andthestmc m isnalntended or offered for
S O sale(Sec 7044,Business and Professions Code:The Contractors License law
s� does nolapply to an owner of property who builds or improves therms,and
whodoeasuchworkhimselforthnu gh hi9wwn employees,provided thatsuch OCCGNOUP RFS.IINTES
improvements are not Intended oroffered forsals.IL hnwevep thebuilding or TOTAL:
improvement bsold within oneyearofcompletlon,the owner-bWlderwill have
to rden of proving that he did not build orimprove for purpose of sale.). QTY, PLUMBING PERMIT FEEPIAO WNNE pPN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mmtmd the project(Sec,7044,Business and Professions Code:
The Contractors License Law does nmol,apply to an owner of property who ��-DRAIN&VENT-WATER(EM
Wada or Improves thereon, and who contracts for such pWjects with a
cq➢t_fador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
(_I I am exempt under Sec. B&P C for this mason 5'�
Owner Date I DRAINS.FLOOR ROOF, COND. <r� SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION a.e�ys RECEIPT M
❑1 hereby affirm that I have a mnificate of consent to self-Insure,ora MTURESPER TRAP cs-�PJ SCHOOL TAX Y N
cenificateofWorkere ComNppgp���s �jjj-/lonlmura or a certified copy thereof(See. RFCELPTN
38M Lab C) I I c'O-1 Q GAS EA.SYSTEM-1 INCAOUTLE1'S PARK I•T:1: Y N
Polirya I I J J — RECEIPT#
Com any_ `moi. ' GAS EA.SVS EM-OVER4(EA) BUILDING DIVISION FEES
.enifiad cop sN T fumi ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF O(EMPPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhissection need not Wcomplcted lithe permit isforooehuncl ddollars SEWER-SANITARY-STORM EA.RIOFT. Date Recei t#
($100)orless.) WATER((EATER )A� ROV 'Z� ENERGY FEE Y N
Ill not thatoythe
an persoummofthe manner so ax
Wspermit c Issued,the TY'lb' _
I shall not employ any person in any manner ao ns to become subject to the '
Worlica Campensatlon Laws of Califomla.Date WATER SY51Lhf/TREATING PAID
Z Z NOTICETO APPLICANT:If,after makingthis Certificate of Exemption, NEW RESIDENTIAL PLMB.
o sQn. Date Recei t#
F O should ode,yobeams,
os eurthwitect the ply with such
provisions
or
rer e Labor TOTAL:
WN Code, A must forthwith comply with ouch provisions or this permit shallW
> deemed myoked. BUILDING FE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z [hereby orkfo wat hich
isaconsimctionlending ;7,Civ.ency c.) perform- TOTAL: L—f ELECTRIC FEE
arm of the work for which this permit u issued(Sec 3097,Civ.C.) 3"
LLQ Landers Name PLUMBING FEE
LLU Ienaerapahall QIW MECHANICALPERMIT FEE MECHANICAL FEE
O W Icertifythatl have read this apph-tt-nand statethattheabdve information
a iscOmect.l agree to comply with all city and munty ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building constmotion,and hereby authonJe representatives of this
F Z city to enter upon the above-mentioned Property for Impaction purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupen Ino Date Receipt#
against liabilities,judg ts,costaand expenses which may In any way accrue AIR HANDLING UNIT(To 10,oO0 CFM) SUBTOTAL:
dCl in (t � ting of this perp{.
i /,& AIR HANDLING UfvTf(OVER ID,000CIM) CONSTRUCTION TAX
ago i L
SI r o it Ilcant/8Pa ra o n L
B PP i MIA EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL ISCLOSURE
Will theapplicant or future building omapant store or handle hazardous HEATING UNIT(TO 100,OOOBM
materials,defined by the Cupertino Municipal Code,Chapter 91Z and the Date RBCei t#
i❑Yrsd Sof=ty Cone,Secdon25531(a)7 HEATING UNIT(OVER 100i No ,,000 BTU) TOTAL: OL
Will the applicant orfuuhmabulldingoccupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 1$ UF�NCE DALE
which coat hazardous air mntaminants as defined by the Bay Area Air ,��✓1J
Quality Mawgement DisWct7 BOILER-COMP 1 00,000 BTU)
Yes ❑❑No
have read the hazardous materials requirerrenh under Chapter 6.95 of BOILER-COMp(OVIR toJ,000BN) r j, 1yyU
the Califomu Health&Safety Code,Sections 25505,5533 and 75534. I
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECFI. SQ.FT.
mapo bibtyto notify theoccupant of the requirenrntswhihmost be met
Ari oulssu c- CL 1 t f0 a -•.., „t �tllnoey,n0
Owner thonud agent Date
'1C3TA L: ISSUED BY: 0 L/{AJCIY./tLJY—`•a.V'e.I
OFFICE COPY