20162 APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES — USE BALL POINT PEN ONLY
Building Project-M flotion PERMITNO.
Building Aim,: _ 201.62
CITY OF CUPERTINO-BUILDING DIVISION
Contract rawLIc.Nce APPLICATION /PERMIT
.4 BUILDING-ELECnUCALPLUMBING-MECHANICAL CATEGORY CONTROL#
ArchiMat/Engineer. Llc:Na:
QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Address - PFRARTISSUANCE ❑ ❑ ❑
Lon that
LICENSEDCONTRI am ACTOR'S
under provisions
ththSyioflrmtlafDlvi =3o(underp ofChapterg APPLIANCFSREBIDEN7IAL JOB DESCRIPTION
It...i Inian70f10)o(Dlvlalon3ofthe Buelneeeand Pro(eaalon,Cade,and my
Ilmnse lain(ulYlo deice#. p PANUS `�
Llmnse ClassLic.c e��ssdl
Dae Contractor —UP TO 200ANTS
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�vv ail pZ l understand my plan shall be used a,publle record& OVER I ODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E�(Oj Licensed Professional SIGNSELECTR(CAL
OWNER-BUILDER DECLARATION' $PppULCIRCUIT
Iherebyaffirmthatlam...mptfromlh,Contndoes Llmnw IAwforlhe
following reason.(Section 70715,Buskers and Professions Code:My city or
kjV
F41"' mortywhich requlreta pendttomrstrud,alter,Improve,demolbh,orrepair 7FAIP.MEIPR ORI'O IN '
azaz en ysuudurepdortoitsAmame,aborequimtheappliantforsuchpermltto ]O
1' WEA
falls a signed statement that he Is Iimnsed pursuant to the provisions of the
3µ'� Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- GPOOL C
„NO� don of the Business and Pmfaxm loCode)onhat he Is exempt therefromand VALUATION
�5µqu Sn the basis forth,alleged exemption. Any violation ofSection 7031.5 by anyI �� `
applicant fora permit subjects the applicant toa#vll penally ofn#momthan OUTLE U
O Eve hundred dollars($500).
❑I,as owner of the property,or my employee with wages as their sok _NEW R AL STORIES TYPE CONSTRUCTION
t7< mmperoationwilld.theworkandthestructure isnot intended or offend for
S ❑ elle(Sec 7016,Buskess and Pmfesimd Code:The Centrad.e.License Law
3 doe not apply to an owner of property who Wild.or Improves thereory and OCC.GROUP: RES.UNITS
doe.such work himself or through hkown employees,provided that such
Improvements are not intended or offered fm sale.If,however,the building or TOT
fImprovement is sold within one yearofcompl#ion,the owner-bullderwill have
t1�rMen of proving that he did not build or improve far purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively mntrading with llemed
coPERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Prcdcado o Code:
The Contndor's License Lw does eat apply to an owner of property who ALTER-DRAIN&VENT WA1IIt(EA)
Wilda or Improve thereon,and who contracts for such pi jests - -with a FEE SUMMARY
ctoKa)Bmx
nd pursuant to the Contradors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sac. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. QIJTqIQE FEES
SANITARY Y N
Date RECEIPTNM
WORKMANCOMPENSATIONDECLARATION FTX7URE5-PER TR AP SCI{ppL TAX Y N
QI hereby afflon that T have o certificateofconsent to selfin ora - RECEIPT M
certltlmteo(Workeri CompereaHan lruuranm oramrtl(led ropythereo!(Sec'
_Z”la77kp�—
GEA. INC.4 OUT
LS PAK FEY_ N—
Z
yb RECPN
T� t01BUILDING DIV
ISIO
N FEESCoBanv � . T
Certfled
c6py,Is hereby fumkhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
E]Cedtfled copy is filed with the city Inspection division.
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARYSTCJRM EA 200FT Date Reccl t#
(This section need n#be compiled lithe permit k(Drone hundred dollen
(5100)utifyth WATER FIEATER W/VENT/m TR ENERGY FEE Y N—
I
that o any personhe In anof y
manner so as to beta permit c cooed,
I shall not employ any person in any runner m as to become subject to the WATER SYSTEM/TREATING PAID
Workeri Compematbn laws a(GII(omla.Date
O Z' Applicant Date Recei t#
Z O' NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT
should became subject to the Worlu rs'Comper adton provblom of the Labor TOTAL:
Code,you must forthwith comply with such provkions or this permit shall be
W j deemed revoked.
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE a.
T hereby affirmthat them Is a construction lending agemy for the perform TOTAL: ELECTRIC FEE
Z aace.ftha work which this permit Is isduA(Set 3097,Civ.C.)
V O Lander.Nana PLUMBING FEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU I certllythat I haveread this application and statethatthe above Information
1 Iscomeal I agree to comply with all city and county ordinances and agate laws PERMITISSUANCE' FEES PAI D:
>. W relating to building roratru#ion,and hereby•uthoibm representatives ofthts .
Z city to enter upon the above-mentioned property for lmpmion purposes. ALTERORADDTOMECH. Date Recei t#
— (We)agree to save,indemnify an d keep harmless the City of Cu pedica -
against liabilities,judgments,mans and expenses which may In any way amue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
againyald City In cmaequenm oft grantingdthh;permit.
ATR HANDLING UNIT(OVER IO,DOOCFM) CONSTRUCTION TAX
Grit til w
Sigruture of Applicant/Contractor Data Ocl{AUSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllmat orfutum building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BT U)
nuterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Flealth and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 7110,000 BTU) TOTAL: t.
Ye No
Will the applicant or lure building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit haurd..air rontsmimnts as defined by the Bay Area Air
4 allty Management District? BOILER-COMPOFI OR l00,OW BTU
Yc. II��II No
av,read the hazar7ous materials requirements under Cha pter 6.95 of BOILER-COMP(OVIR 100,000 BTU)
the Glif urd.Health&Safety Cod,Sect low 25505,25533 and 25536.I
undenta nd that if the building doe not currently have a tenant,that It is my NEW RESIDENTIAL MECO. SQ.FF.
responsibility to notify the occupant of the requirement which moat be met
.Prior t uanm of a Ccrtiticatcof parry.
Owner or au�av- thmized aged Data j\�/#�)R��f'^Inr�.(�
TOTAL: ISSUED BY:\J�
OFFICE COPY �_