20233 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'eet Identification 7 PERM NO.
Building Address: n O�]
•016 N1tv . Z �o v G G
n s 33
done: one: A
es, Zl 7 -0c 4CITY OF CUPERTINO-BUILDING DIVISION (},�
Cont .'.N ame:Milk 'jo� Lte.xn: APPLICATION / PERMIT �\ �U
�-- BUILDING-ELEOTRICALPLUMBING-MECHANICAL CATEGORY CONTROLX
iters/En ne LleNo. BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRAROr pr DECLARATION
I hereby
ectionaffirm 0)ofDmlicensed 3ofthe usin Laions of nd Pmfe Chapter (cormounc,
my APPLIANCES-RESIDENTIAL JOB DFSCRII'1'ION
Ingwhh51.fon 7mcvafd effeon3o(the Buainessand Prolesslons Code,and my
license Is In fuB Igrod and effect. PANELS
License Cyea�_�n Czntrukr
Datefi �—Contractor
ARCHITECPS D'CLARATION 201-TWO AMPS
O7. Iundentand my Flom ala8 be used upublic records. OVER 1000 AM SQ.FI.FLOOR AREA $/SQ.Ff.
COC
`j Licensed Profeesbml SIGNS ELECTRI
6 OWNER-BUILDER DECLARATION SPECWLC T/
p., Ihereby afOrmthat lam exempt from the Contractor's License Law for the
Z following mason.(Seaton 7031.5,Business and Professions Code:Any city or P,METE ST.
ta
1,4 H@a countywhich requiessa permit tocomuct,alter,Improve,demolish,orespair
aq 9.a anystmMmpdortoltsbsuancgahomquirestheapplluntforsuchpermitto
DENT
K Ne a signed statement that he Is Brensed pursuant to the provisions,of the
0w Cgntraaor's Licemelaw(Cha)rter9(commenctngwith Seaton 7000)o(Divl- NCE
30�' slon3ofnhe BusWtevand PryfeslamCode)orthat hebeum therefromand VALUATION
O S the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLE Fl a�V W
applicant fora permit subjects the applicant to a civil penaltyofnet morethan Z
five hundred dollars(S500).
❑1,as owner of the property,or my employees with wages m their sole NSW R A STORIES TYPE CONSTRUCTION
C7compensation,will dathe work,and thestructure is net intended or offend for
5' sale(Sec.7614,Bushton and Professions,Code:The Contractors License Law
a
�$$ does not a pply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself orthrough his own employees,provided that sv<M1
improvement are not intended or offered for sale.If,however,the building or TOTAL: 3
improvement issold withinone yearofcompldiomtheowner-builderwill have
tr"rden of proving that he did not Wild or improve for purpose of vis.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting vmh licensed PERMIT ISSUANCE
contractors to construct the project(See.7M4,Business and Profsssiota Code:
The Cgntvaorb License law does net apply to an owner of property who
Wild.or improves thereon, and who contracts for such punjeas with a ALTER-DRAIN&VENT-WATER(EM
,,natthIactor(.)licensed pursuant to the Contractor's License Law.
FEE SUMMARY
cLJ I am exempt under Sec B It P C for thb reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAK Y_ N_
hereby affirm that I have a certificate of consent b self-Insure,ora RECEIPT N
certificmeofWork m'Comper timltsuranamacertif4dcopythemof(Sec. GAS-EA.SYSFEM-1INCAOUTLETS PARK FFR Y_ N_
3800,Lab Cd Policy N _
C - I/ , LI.,,✓ '�Qf� GAS EA.SYSTEM-OVER4(EA)
MRECELL'1'M
BUILDING DIVISION FEES
Cceitfled Where fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANHARY-STORM EA 200FI Date Recti tlf
FIN,salon need not be completed if the permit bfor one hundred dollars
($100)orless.) WATER HEATER W/VENC/ELECTR ENERGY FEE Y_ N_
I certify that b the performanceof the work fgrwhich this permit b Issued,
I shall not employ any person in any manner so as to become subject to the WAITR SYSTEM/TREATING
Worker:Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL 1'LMB. SQ.FT. Date Recel tN
Z U NOTICE TO APPLICANT.if,after making this CertBicate of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
Xp) Code,you moat forthwith comply with such provisions or this permit shall be BUILDING FE'
W ) deemed revoked.
CONSTRUCTION there
eumoN LENDING AGENCY SEISMIC FEE
CL n O Ihereby work
w therebaromtmction sucol(dknga97,CF,.CJ perform TOTAL: ELECTRIC FEE
0 Z anceofthe work(or which this permitIsblued 6ec 3097,CIv.CJ ULender's Name PLUMBING FEE
LyL r LdnLea
kadrsAaarcsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Im,ct.Ia re he comply this alldty.ad sncrymuheabo..d datela n FEES PAID:
0 W bcormct.building complywo,andtyandrouh.os,representatives
and date olawe PERMIT ISSUANCE
} a relating
oenterbuilding construction, d property
or In rcpresenhRves of this
F N ci(Wenteree to saeaWve-mtentbmd propertyfor w the Cin purposes. ALTQ4Oft ADDTOMECH.
? (We)agree to Cave,InddmNfy an d keep es which
the City o(Cupertino Date Receipt.)
V
against liablBues,ydgntents,cwtsand expenses which may In anywayamue AIR HANDLING IIMT CFO 10,000 CFM) SUBTOTAL:
aga out said City to consequence of the granting of this permit.
AIR HANDWNG UNIT(OVER)O,OW CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date D(HAUS"IHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le havrdous HEATING UNIT JO I OO,ODO BTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the OXY
Flealth and Safety Code Scaion 25532(a)? EMATING UNIT(OVER 100,000 BTU) TOTAL: xW
0 Ye, C3 No
Willtheapplicant or future building occu pant use equi potent ordevics VFNFIATIONFAN(SINCLERESID) U CE DATE
which emit havrdoua air contaminants as defined by the Bay Area Air i
Quality Management District? BORER-COMP OIIP OR 100,DOp BTU)
a'J
4M1averead the hzarduusomaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that lfthebullding does not currently have ate na.I,that it Is my NEW RESIDENTIAL MECH. SQ.FT. ayanpl{1fI��
respomibllitytonolify theoaupant of rte requimmemswhich must be met '(,AHat l�
prior to(,L�s1Jsup/an�m/+]o'r/a�Ce�rtiflote of Oc _.f
a 'tet-t-N�tVy�'(���,1sr��yts, ,Ly�����t�
Owneror auth iced agent Data ISSUEDBY bz V J��"'a= v��
TOTAL:
OFFICE COPY