20802 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFJMT NO.
- Bu llding Add raw if, /�O O O
10431 ' � G o
Trmne�as acre: q one:
_� 4Pp , � 1?' '(OtD CITY OF CUPERTINO-BUILDING DIVISION p
c°ntra°nr Name: Lie.No: APPLICATION I PERMIT 177
Nli BUH.DING-ELE-CTRICAI.PLUMBINGMECHAMCAL CATFL-ORY COD/CR/,U /Z
Amhlt /Engine r. Lle No: GO �Y
G , QTY ELECTRIC PE MIT FEE BUILDING PERMIT INFO
Addmss: Do(� (�AIJ�►a cap. PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATI N
Ihereby affirmthat lam hemsed under pmvWonso!Chapter 9(commanc, APPLIANCESRESIDNTIA .JOB DESCRI'TION
Ingwlth Sedion70OD)of Divlelon3olthe BuMn .ndPmfessimsCode,andmy
nse ce
lib in fug force and died. PANELS T-s_ --
It
LION
Date Cmdratlor t✓-+�— t~LI
ARCHITEC'S DEC ION M14"AMPS
X2 I understand my plats.hall be and as public remade. OVER1000 PS SQ.FT.FLOOR AREA $/SQ.FT.
bo
O
z� Lice"sed Professional SIGNSELD
IMOWNER-BUILDER DECLARATION SPECIALCIRC LSC
ZI. 4 [hereby af0rtn that l am exempt from the Contractor'.License law for the
0�..
following....(Section 70)15,Business and Professions Code:Any city or ME1TR I
P I' county which requires a permit to cans[rod,alter,improve,demolish,or repair
N§°"1 .� anyetrodure prlorto its bssame,aborequlresthe applicant for such perntto PO DEV
O file a signed statement that he b It...d pursuant to the provisions of the
}g( se Comractoe.License Law(Clupler9(commenWgwith Section 70W)ofDivi.
`1 O don3 ofthe Busimuuand Prvfwbv Code)orthat he h exempt there(romand S LELCCTRIC VALUATION
-
�50.q+ Q the basis for the alleged exemption. Any violation of Scan 7031.5 by any OVILE.IS •fCEfESH%711RE5
appllantfora permit aubjedathe appllcanuoativll penalty of not more than
$ fivcbundred dollars(SM.
1 as ownerof the properly, NEW ENTIAL ELECTR SQ SIC)RIES TYPE CONSTRUCTION
�n p party,or my employees with wage.as[Mir sole
compensation,will It o the work,and the structure h not Intended or offered for
C O sale(Sec.7004 Business and Professions Code:TM Cm arectors License Law
$ does not apply to a,owner of property who builds or improves thereon,and
w who does suchwork hirselforthrmugh his own employees,provided that such OCC.GRO(1P RES.UNITS
improvements am not Intended proffered forsale.If,however,lhebullding or TOTAL:
Improvement issold within one yearofcomplelbn,theowner-builderw111 have
t)g�rNao of proving that M did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APNr
u L as owner of the property,am exclusively contrasting with Ilceved PERMI]'15511ANCE
centactors to cowtroct the project(Sec.7000,Bushes and Professlas Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or Improves there°,and who contracts
for such project.with a
oqn([+ctort.)Hemeed pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
LJ I am exempt under Sea 0 k P C for this reason
OUTS I DE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEBT a
WORKMAN COMPENSATION DECLARATION FIXTURF&PER TRAP SCHOOL TAX Y_ N
QI hereby alarm that I have a lrtcone of consent to pytheure,or RECEIPT IF
38M,uftifiabofWorken'Compewatlon lruurance oracertlllN copytherro((Seo. GAS EA SYSTEM-1 INCA OUTLETS PARKFER Y N '
3800,Lab C.)
P9"C' GAS EA.SYSTEM-OVER 4(EA) RECEIPT#
Com an BUILDING DIVISION FEES
CCengi dcopyb(i b tht adty CREASE/IYDUSML WASTE INTERCEPTOR PLANCHECK FEE
�Ceni ied copy h filed with the city Irupedbn dlvl.lon.
CERTIFICATE OF O(LTI PITON FROM WORK ERS' GREASE TRAP PAID_?/Zslo�7 ��ss
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t# 60,
(TNexdlon need not M completed H iM pertNt b!prone hundred dollars
($100)°r less') WATER HEATER W/VENT/ELEC7R ENERGY FEE Y N
I certify that in the Performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
Workcri Compensation lawsof Califomla.Date WATLR SYSTEM/TREATING PAID 7/S"Yq�
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t# 5L7aL
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provistors of the Labor TOTAL'
� N Code,you must forthwith comply with such provisions orthls permit shall be BUILDING •f7
W > deemed revoked. '
Il o CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
I hereby affirm that there is a construction lending agency forthe perform
TOTAL: ELECTRIC PEE
7 Z ante of the work(or which thio crmithLssued(Sec.3097,Civ.C.) _
U O Lender.Name PLUMBING FEE
ly 1- Lender.Address — QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
ObroI certilythat l haveread th appliatlon and Asia ihattheabovetofomstlon
W rrect.lagre t.complywlthalldtyandcountyordlnan....d state laws PERMIT ISSUANCE FEES PAID:
>' relatingtobulldhg construction,and herebyauthorlu representatives ofthis
I"' Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Dale Recd [#
V — (We)agree to save indemnify an d keep harmless the City of Cupertino
agaWtliablllties,judgmenb,mats and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,ODDCFM) SUBTOTAL:
against said ity In consequence of the granting of this permit.
f2 AIR HANDLING UMT(OVER Ifi"CM) CONSTRUCTION TAX
Signature of Ap ant/Contractor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 RM Date ReeDl [#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and SdctyC Ion 25537(a)T HEATING UNIT 10,000 BTU) TOTAL:
❑ Yes
Will thezppliant 4wre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUM "'DATE
which emit hazardous air rontamtrunts as defined by the Bay Area Air p/k
Quality Management Dht ctT BOILER-COMP GHP OR 100,000 BTU) PAID
Yes No
haveread the h. o rtuterials requirements underChapter 6.95 of BOILER-COMP(OVER100,WD BM . 1990
the California Health k SafetyCode,Secilom25505,25533 and 25530.1 G 16 1990 -
understand that if the building does not comantly have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT. /. /I .a,
mpomibilitymnclifythooccapantofthrequlrementswhichmustbemet, rI City of CBBeftYBB
prior to Issuance of a Certificate of Ocxupanry. I y Bf f;IIBPftinn
�iSln vt p Lia��/Jct r ?125�te
Owner rauthorlad agent ( pite ISSUED BY:
TOTAL:
OFFICE COPY