21875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PLRNUTNO.
Building Address:
1�'zS%� ?a 2�ti87
sonars ame: one: A. -
T wa Q ��t1uJ'(�—l_ CITY OF CUPERTIN0.BUILDING DIVISION
Cum Lie.R� Lie.No: APPLICATION /PERMIT �2Gr�L
t
W ArcMtre/Engineer. Llc.No: BUILDTNGII,EC7RICALPLUMBINGMLCHAMCAL CATEGORY CONTRO 39
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICF,NSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DF ON
Ingwith Section )of DiWgm3ufthe Businessand PmfessionsCodpandmy
IImnY force and effect. 32-7 - PANELS
se Chen Lk L-J J�Itl\-�1W
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
p�++a7 I understand my plans shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA E/SQ.FF.
Q U Licensed Pnefemlorul SIGNS ELECTRICAL es C,So � ��s LZ-
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC xR'-h1�1 t� or% "
foll
Z thereby .(Sem affirm that l aexemptfrom the Contractor's License Law for the �QC
owing.. ction 7831 S,Business Professons Any city or Code:A
O usiness anTEMP.MITER ORIOLE INST.
P4 rountywhkh rcqulma permRromrulrvuirestheapmve,demalbh,armit to
any atmcturcpaler teits hathecgabensed pestheat to the,(onuch ions of permitto )OWER DEVICES
file a signed statement that he V licensed pursuant to the provisions of the
Contractor.Lt..Law(Chapter 9(commencing with Section 7000)of Divi- SWpghgNG POOL ELECTRIC VALUATION
f,�OJ sion3ofthe Business and ProfeeslonaCode)orthat he b exempitherefromand
6..••7777 the baa.for the alleged exemption. Any violation of penalty
ca 78715 re any OUILETSSWIICHESFIXTURES (7,Q
the bunt fora permiged exemption.
vioa ion f Sects of not more than �J
flue hundred
owner
the pr). NEW RESIDENTIAL ELFLTR SQFT. STORIES TYPECONSTRUCTION
'9..' ❑I,
as owner of the property,or he employees with wage as offered
sole
C rompere.70n,willdothe ess and rk,Pr and lhes Code:The Contractors Mendedo icense Law
5 0 dile(Sec. pply to alnow andf property Co.:The orImpLiroves t cense Law
Was—
�js>� does noes such loanownelofthroug hisonem oyse%prvidedtoryand OCC.GROUP RES.UNITS
GG
who does nor msededreough hleowneee .If,hoeencr,thebuilat such ingor
Improvements auld wintendneyearferad ptetio.I(,howar-builderwdl have TOTAL O )L
Improvement V cold withinaneyearo(completlory theawnnnbu0derwBl have
tl)g,purden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with Incensed FLOOD ZONE APN
rontnctem to construct the prefect(See.7094,Bualnessand Pretensions Code: PERMITI.SSUANCE
The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
builds or Improves -thereon,and who contracts for such pkajects with• FEE SUMMARY
c75actor(s)licensed pursuant to the Contractor's Llmnse I. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for this reason
OUTSIDEFEES
Owner Data
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT if
WORKMAN COMP F cenifi ON DECLARATION FDCnJRFS PER TRAP SCHOOLTAX Y N
❑I hereby affirm that 1 have• lmumnc of consent d pythuam,ora RECEIPT 0
3800,Lab mdifluteof Worken'Compen+atlonlruuranm oracertified ropy Hereof(See. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.)
Policy p CAS F.A.SYSTEh]-OVER 4(FA) RECD B
Cama BUILDING DIVISION FEES
eeified copy V herebywith the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
' ❑Certified mpybflled with the city lvpectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAJD7=2Gr LI �oC ,.I�.,/�
COMPENSATION INSURANCE SEWER-SANTTARY-STURM EA.2XFE. Date REceI H` V��
Ohne section need not becompleted If the permit Internee hundred dollars
IS)00)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I senor that o the performanceof the wwkfor which this.caseins issued,
I -h k not employ any.L,m In any mannerso ss to become subject to the WATER SYSTEM/TREATING
Workers Compematbn Lowe o(CaII(omla.Date PAID
—
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei t71
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subj cl to the Workers'Compensation provisions of the Labor
fq Code,you must forthwith comply with such provisioru orthb permit shall be I sZ� BUILDING rt
W deemed revoked.
ILCONSTRUCTION LENDING AGENCY SEISMIC FE _
Iherebyafflrm,hat them V acomtructlon lendingagency forthe perform- aT� 'LEGTRIC E
Z anteofthe work forwhlchthis permit V Issued(Sec.309'7,CIv.C.) TOTAL: `O`a2
O O lender.Name PLUMBIN FEE t I
U. F Lendds Addmna QTY. MECHANICAL PERMIT FEE MECHANI LFEE ( I
OW Imrtlfythatlhavereadthieappllcalionand stalelhatthe above Information /�T
IL .correct.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE ( .e.a.� FEES PA
} IL relating to building construction,and hereby authorize representatives of this
F U) city to enter upon the above-reent"oned property for impaction purposes, ALTFRORADDTOMECH. aft eCel tic
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against Babilltles,judgments,costa and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CPM) TOTAL'
agalmt ssid Cl In mnsryue (the granang o(thb perm",. ^d
-. AIR HANDLING UNIT(OVER 10,"CFM) C STRUCTIO TAX X19
I tureo p rat Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCI'1 TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcznt orfumrebuilding occupant store orhandlc hacardous HEATING UNIT(TC1101,000 BTU) Date Recel to
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
I lealth and Safety Code Section 2 31(a)? HEATING UNIT(OVER IW,000 BTU)
❑ Yea No
Will the applicant or Lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit luzardoua air mntamivnls as defined by the Bay Area Air
Quality Management District? BOILER{OMP OHP OR 100,0(0 BTU)
Yes
n❑No
- ?havereadthehazardoua.terialomquimmenbunderChapter6.95of BOILER-COMP(OVER 100,DOD BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534.1 MAY ,?understand that if the building does not currently have a tenant,that 11 is my NEWRMI)ENTIALMECH. SQ.FT 'fJ ,? r` r
'responsibility to notify the occupant of the requirements which moat be mot
—
priortolssuanceofaCertificate of Occupancy.
Owner or aulhorlmd agent Data
TOTAL: V �. ISSUED .
OFFICE COPY