20649 APPLICANT TO FILL IN INFORMATION WITHIN R N SLLP T FEN ONLY
Building Project Identification PEILWT NO.
B. ing Address: N 20649
o D�
one: I Phone:
CITY OF CUPERTINO-BUILDING DIVISION q
§ep !. 9ILL16 N . APPLICATION /PERMIT 2=
BUILDING-ELEcnUCAI.PLUMBINGMECHAMCAL CATEGORY I CONTROL N
- - - QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
with Se ion700hallam licensed undersmassmad of Chapter 9(rommeno- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IngwlthSMion7000)of gvlalon3o!/Y,Ryrued (aaelBl(iCade,andmy
liceR
se In PANELS
Dat
License Cla® Cent
e ^ ContndarUP TO 200 ANTS
ARCHITECT`S YTio 201-IODOAMPS '
q�v aO Zp I undersea d my plans shall W used as public records. OVERIfpOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
d Licensed Profeasimte SIGNS ELECTRICAL ,
OWNER-BUILDER DECLARATION
1T) SPFCIALCE2CUIT/MISC
x7, owing reason.
that I Sectio mexempt
ustrom ed Professions
License Lw fort he
O q followingreason.(Section70315,constructand Profenlone CdcAny city or
county which requrevapermit tomvtrud ro
construct, mLLvb,
deoh,or repair TEM mrrtR OR POIJWNST.
any structure prior to its Jamance,also requires the applicant for such permit to
oy2 file a signed statement that he Is licensed pursuant to the provisions of the DEVICES '
3 w�, Contndor's Llceruelaw(Chepter9(mmncncingwith Sealon7000)ofgvi- h POOlrELEWRIC
SOS ekn3.fthe Bu.lneae and Pmf.W.Cod.).rthathebexemptthercf...d VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any _
« applicant for a permit subjedatheapplscant to a civil penalty of noun,not othan VTLE TCIIES ES
it undred dollars($500). t
1,as owner of the property, m7 employees g A TE STORIES TYPE CONSTRUCTION
�n p petty,or em k sawithen d r theresok
compce.70Kaflor,wildothBusiness work,andthes Code:
brunt Intended or offered for
Orule(Sec.apply
to an
df property
Code:The ori p oh Lice law
$ dacenot applytoanowerofproperlywho nem orimprovesthe ryand OCC.CROUP RES.UNITS -
imodovants,ant ktIntenedornughedownle.If, en,provlo I t ch or
Improvementaarenmmtenddearofcedforeab.ILhowev. I at it
or '� AL:
Improvementbsold within oneyearo(cwnpldlorylhc owner-bulklerwll a e
tlakurden of proving the he did not Wild or improve 1 purpose area ) QTY. PL BIN RM i, FEE
u L as owner of the property,am exclusively contnding with Ilcen FLOOD ZONE APN
contractors to mnstmet the project(Sm 70K Bu3m ami Pro(embvC IT ISSUANCE 4
The Contractor.License Law does not apply to an owner of property soh ALTER-DRAIN W (EN
Wilds or Improve thereon, and who mmnda for each pPjed.with a FEE SUMMARY
myjlWw(s)Ilcenwdpunuanttothe Cmtmdors Llnnae Law. B FLOWPROTECT.DEVICE
L_I I am exempt under Sec. B k P C(or thio reason
OwnerDate FLOOR ROOF,AREA, SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑1 hereby affirm that I have a certificate of consent to aelWoure,orFIXTUlb� PER TRAP SCHOOL TAX Y N
Ae ndlficseafW kin' ompe Bonlnsu ceorace Ifiadmpy, ereof(Sec. RECEIPT#
3800,lab C.) ` GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE RECEII'TN
Po14yY I GAS EA.SYSTEM.OVER4(EA)
Com any / BUILDING DIVISION FEES
�Ceri Bed (um - CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
s� ❑CerlPred copy b filed with the dty Wp.c km divis on.
l ll� CERTIFICATE OF EXEMPTION FROM WORKERS' CRRASFTRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM E.A.200Ff. Date Recei t#
(This section need not W completed lithe pem dt blur one hundred dollars
($100)orless.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
1 I certify that In the performarmof the work forwhsch this permit Is blued,
I shall not employ any person In any manner so as to become subject ro the WATER 51,5118.1/TREATING
Workers'Compensation laws of California,Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLM9. SOFT. Date Rewi I#
Z NOTICETOAPPLICANT:If,after makingpesationthis 1procate o(ons of the
Labor
F eode,yohould become,subject to the ply with
Compensationprovisionsmthb;permit s Lab be TOTAL:
Code, amost.ked.forthwith comply with ouch provisions orthb permit shall be
W deemed revoked. — BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL t hereby affirmtwhichtbamnswdsonledee. D97,Clforthe per(orrtr ELECTRIC FEE
Z ance Landerlhe work forwhkhthio permit lalaered(Sec.3097,Civ.C.) . TOTAL:
O O Lender's Name PLUMBING FEE
F Lender:Addreaa QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
tion
O W omed. that
agreet comple read lWapaBvatynand dcounte that theyordina above dgat laws
a le mann.Iagrceto complywith
on,and tyandmuntyodrepreaand gate laws PERMTTISSUANCE L FEES PAID:
} cityrelato gtobupon t mabove- oManddprope property
ori in rcpmenpurposo(thb -
N 0-
city to enter uponlM above-mentioned and keepertyolonahMkn purposes. ALTER ORADDT'O MECH.
Zt,11=2
veindemnify and keep harmless the Ina y Cupertino Date ReCei t#
is,merea d expenseswhichmayInanywayacvue AIRIiANDL1NG UM7(TO 10,000CPM) SUBTOTAL:
old CityIn a encs of he gra ng of this permit. ))))
,- AIR HANDLING UM'r roVFR 10,0BB CFM) CONSTRUCTION TAX
Sig Appa o r to D(HAUST HOOD(W/DUCT). 'CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA CLOSURE M
Will the applicant or future bulldln tore or handle haadous HEATING UNIT(TO 100,000 BTU) - VV he . Recei t#
material as defindb cel pa1C e,Chapter 9.17,and the
Health and Safety Code Section 25532(a) HEATING UNIT(OVER 100,000 BTU) TOTAL:
1Yea M No
llthe applicant or(union building accopant use equipment ordevsm VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harzdous are contaminants as defined by the gay Area Are
antyy Management Dbtdd7 BOILER-COMP DEEP OR 100,000 BTU)
Yea No
a vereadtheharardous malcriats requirements under Chapter 6.95 of IIOILER-COMp(OVER imace B'IU) �� �3 ycJ-yJ
11 1.Health A S. Cdens,Sedso25505,25533 and 25534. I ' 1
on n nd that sfthc Wll oc.not rrcntly have atenant,that ltbmy NEW RESIDENTIAL MECO. SQ.FT -
ibBllylonoUtyth pant oft erequ menta which=at t
park orfs Ce if t Oc an I.
net orauthodzd.gem _-Da ISSUED BY: 4t s'W
TOTAL .D
OFFICE COPY