20170 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildiin••�� Project Identlficatlon PFjWTNO.
BulldlI SID t m 2 D S rz 20170
ANweer. II.. one:
)TA ttz SA l CITY OF CUPERTINO-BUILDING DIVISION
C ntn nee erne: Lk.No: APPLICATION / PERMIT —/
D O BUILDMGQ.FiCTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROL M
ArchimettEngineer. ' Lic N.
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmw PERMITISSUANCE �• ❑ ❑ 11LICF.NS ED CONTRACTOR'S DECLARATION
I hereby&fflmthat lamosofoen APPLIANCSFRESIDENTIAL JOB DESCRMTON
Ingwlih SdM.n7000)ofDlWxIdn3.fh.B.sinrM;s.dProfcsMmaCd.,aad
my
license is In f(yy o effect. / PANELS
LlcxrDote! Cb Lmm
DateL�__L. p/) CHITECrSVC_LL /12Y IrG--
7'f"Ty ARCHITECPS Dmp TIO OVERI0AMP5 [
M0 73 Iundentand my playsMBbe used apubilcrcmrda OVER IOW AMPS SQ.FT.FLOOR AREA 5/SQ,FT.
Licensed Professional SIGNSELECTRICAL t�
«6OWNER-BUILDER DE
rn a a
7F" Ihcmbyaf(irmDECLARATION
that Contractor's License Law SPECIAL CB{CUT/ ISC
following mazon.(Section 7031,5,Buslnd Professions Code:An cityor
Fs'm ancounty which mfama a permit to construct,alter,Improve,demolish,or reair TFMP .METIROR
'� any smacture prior to its issuance,also requires the applicant!..such pe 7,7"t"10
dt to DEVICES
file a signed statement that he b licensed pursuant to the provistmu of the
BOw1� Contractees License Law(Chapter 9(commencing with Section 7000)of Dial.
OJ stun 3.f the Business and Professiom Code)or that he is exempt therefrom and S CIX]O CTRI VALUATION
•77 the basis for the alleged exemption. Any violation of Sce lon 70313 by any �J g Zd pO
appllantfor a permit subjectsthe applicant to a civil penalty of nor rrore than QUILL• a
floe hundredsowner
she M.
pro NEWRESI Al, 1R S(ORIFS TYPE CONSTRUCTION
�n ❑I,as.wnw will
the property,or my employees with wages r thele woe
compensation,Business, work,andthertmctureh norintendedor offered for
q ale(Sec. pply Bu slowandf pmp vCode:The or
pees License Law
dons norsuch loan ower of p rough who own employees.
lmprwn lMrean,and
EE whodoes such work himseUorthrwgh hleawnempigeea,provided that such OCC.GROUT' RES.UNITS
Improv nbarenotintendedorafferedforwle.It,however,thebuildingor TOTAL:
Improvement issold withinooyearofcomplebn theawnerbullder Mll have
HfIIiudenofpmving that he did not build or Improve for purpose ofeakJ. QTy. PLUMBING PERMIT FEE FLOOD TONE APN
LJ I,as owner of the property,am exclusively contncHng with licensed PERMIT ISSUANCE
contractors to conatmact the project(See 7014,Business and Pro(cesiov Code:
Taa Contractor's License Law does out apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Impr.va thereon,and who contracts for such p{ojects with a
�g0f(actor(q hensed pursuant to the Contractor's Lt...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ f am exempt under Seo B k P C for this reason
(111T�Inr F1
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y_ N
Owner Data RECEIPTY
Of
here WORKMAN COMPENSATION DECLARATION pp(?{7f{gg PER TRAP 54i00L TAX Y_ N
by affirm that I have a certificate of consent to self-imuce,or RECEB NN
38M Lab�)
abofWorken'CompevaHonlvunnce ora certified copy there.((Sec. GAS EA.SYSTFM-1 INCAOUTLETS PARK FIE Y N
Pwi ollry Y tI// RECEIPT DI M
GAS EA.SYSTEM-0VER d(EA)
uny p �rA-r4 Ae �_ BOLDING DVISION FEES
L
Cenlnc o y fire turn V e . CREASE/INDUSfI{L WASTE INI'FACEPTOR PLANCHL•CK FEE
CertNed ropy is filed'Mth the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA MOFT Date RC i tin
(fhieeectlon need not Mc.mplcted If the permit is!.eons hundred dollar
($100 mless3 WATER HEATER W/VENT/ELGCTR 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 WATER SYSTl3.1/TREATING
Workers'Compensalion Laws of California.Date PAID
C' Z Applicant NEW RESIDENTIAL PLMB. SQ.IT. Date RCCCI I#
Z O NOTICE TO APPLICANT:If,ofter ma king this Certificate.(Exemption,you
-� should become subject to the Workers'Compensation provbiov of the Labor TOTAL:
N Code,you at forthwith comply with such provisions or this permit shallbe
> deemed revoked. G •E �- V
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.filthat there is a oavtructlon lending agency for the perform, ELECTRIC FEE
M Z aaa.ftha workfor which this permit bissued!(Seo3097,CIv.C.) TOTAL:
02 IendoesName PLUMBING FEE
LL F Mndee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lardfythaHMvemadthbappRatianand atethattheaboveinforma ton
a Isconact.I agree to complywith all tltyand county ordinances and a iaws PERMIT ISSUANCE FEES PAID;
} N relating to building covtructlon,and hereby authorize representatives edible
F Z city to enter upon the above-mentioned property for impaction purposes, ALTER ORADDTO MECH. Date Recel til
_ (We)agree to save,Indemnify an d keep harmim the City of Cupertino
against liabilities,judgment.,costsand expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against yyd City i consequ nc ofthe granting of this permit.
!h ,;7 S_)-90o AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signat{rre of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle ltnrdoua HEATING UNIT(TO I OO,MO BTU) Date Recet tp
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I leall It and Safely Cod c Ion 25537(a)? HEATING UNIT(OVER 100,000 BTU TOTAL:
❑
Y. No
Will the a ppliant. future building.avpant use equipment..devices VENTILATION FAN(SINGLE RESID) ISSUWd ATE
which emit hazardous air contaminants as de0oed by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
F—I Ye e.N. J
`T�avcmad teeth& ow natde,Sections
25505,25S33 and
of ROILE&COMP(OVER IOO,000BN)
theundCalifornian laat If the
building
Code,not currently
a tenant,
'espretanlitytoftify the occupant not hermntiy Raves tenant,that Itbray NEW RESIDENTIAL MECF{. SQ.FT. City of Ptincirtin0
roponsibllity b not l(4,the occupant of the requircmenb which must 6r'mer y
priortobsuanc of.Cert ta.fOmpanry.
Owner or authorized agent /-- Data o ISSUEDBY: L
TOTAL: —
OFFICE COPY