20176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Builds Project identification PERMIT NO.
Building�d9+ 12o7 eP-s HATCH — CGS' � 20176
w.c'. xme: one:
GENT PLES R/4. )S2-517 CITY OF CUPERTINO-BUILDING DIVISION qp
Contra or'eNa Lie,No: APPLICATION /PERMIT v'
G pr-_ SSO BNLDING-ELECTIUCALPLUMBING-MECFIAMCAL CATEGORY CONTROL#
Architect/Engineer. Lk.No:
QTY ELECCRICPERMIT FEE BUILDING PERMIT INFO
Address: PFRFRT[SSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I herebySectio700D)olam BcensedheBusirovbldPmfhonsCodeann AI'PLIANCFSAESIDENITAL ]OBDESCROsT10N
Ingwlth Section 7000)of Dlvlelon3o(the Buelruseand Pro(ntloneCade,and my -
H'I�
licenesisInfu-fo effect.�3 r
nse Cl01
PANELS //
Licea Lt.N_(_ ��
Dat Contractor s Er'
ARCHITECTS ECLARATION 201-10DOAMPS
92 IundentandmyplamehaBbeuwdupubhcrecords. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
ZCO
`j Licensed Professional SIGNS ELFCP.UCAL
6N OWNER-BUILDER DECLARATION SPECIAL CIRkUITjMISJ 10—
X2-4 Thereby affirm that l am exempt from the Contractors License Law for the
ppp following....(Sector,7031S,Business and Professions Code:Any city or
muntywhkhrequlreaaper twmmtmd,alterfinpmve,demolbh,ormpair TEMP.METER POL IN
S� anystrucurc prlortolta issuance,also requlresthe applicant forsuch permit to PqNER DEVI
l=!O s file a signed statement that he Is limned pursuant to the ProWtoro of the
6
� In C°ntncor's Lkerme Law(Chapter9(mmmencingwlth Section 7000)o(Divt- hRNG L
SOS slon3ofthe Bustnesand Professla.Code)orthathebexemptthercfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any O FTS XTUR / C�
applicant fees permltsub(ecbeSU
the applicant to a
civil pevlty of not more tiara V
five hundred dollars(>M. Mi ENTIA ELECTR
❑I,as owner of the property,or my employees with wages a a their wk �'FT' RIES TYPE CONSTRUCTION
mmpewtlory wllldothe work and lhertmRure boot#tended oroffercd for
I iLO sale(Sec.7044,Bushes and Professions Code:The Contncota Llcerue Law
♦V,i$$ does not apply to an owner of property who builds or improves thereory and OCC.GROUP RFS.UNITS
C; whodoneuchworkMmeelforthrough hteown employees,provided that such
Improvements are not intended or offered for sok.If,however,the building or TOTAL:
improvement bsold wlthinaneyearafcompletion,the owner-builderwfil have
to,S.Ilurden of proving that he did not build or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
LJ L as owner of the ppe ty,am exclusively contracting with licensed bT.00D TONE APN
o
contractors to construct the project(Sec.7044,Business and Profenlons Code: PERMIT ISSUANCE
The Conte does License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA)
builds or improve.theorem,and who contras for such inpiren with • FEE SUMMARY
�nf�actorW ficensed pursuant to the Contractoe.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this mason
DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N
Owner Date RECENT M
WORK MAN COMPENSATION DECLARATION PIX'NRES-PERTRAP SCIi00L FAX Y N
❑1 hereby affirm that I have•certlfiate of consent to opyth.mcd or RRCEB'T N
cecilleste of Worken'Comperuabonlmuranceara certllled copythercof(Sec. GAS EA.SY5TEM-1 INCA OUTLETS PARKFER Y N
3800,Iab CJ
Pell p GAS EA.SYM714-OOVER BIND DIN
Com any tlU1L1NG DIVISION FEES
Certified copybhercby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHE-CK FEE
CertBied spy b flled'wlth the city Ivpectl°n division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2f0FI. Date Reeei t#
Ohleseclon need not he completed If the permit b f°rone hundred dollar,
s1m)nrlen.) WATER HEATERW/VENT/ELECTR ENERGYFEE Y N—
I
(certify that Nthe of thewok forwNobpermit Isbored,
I shall not employ any personrain N any manner so an,to become eubjea to the WATER SYSTEM/TREATING
Worlican Compenaatlon laws of Call(omla.Date PAID
z Z ApplicaNOTICE TO
NEW RESIDENTIAL PLMB. SQFT. Date RtBmi t#
Z Q NOTICErnme subject
tothe,after orkers ompeng Certificate you
Code,shoulyou
most
eforth it the Workers'Compemrisins or
permIhe Lab be TOTAL:
IY N Code,you mustforthwith comply with each proWloru orlhb pemdt shall be O
W C deemed revoked. I
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
M Z ance of the work for which thin permit b Issued(See.3097,Ci¢Q TOTAL:
02 Lender.Name PLUMBING FEE
LL Lender's Adde, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 certlfythat l have read th(sapplianut
tion and statethattheabovelnforlon
IL lecorrcet.Idgree to complywlth all cityand county ordinance and state laws PERMITISSUANCE FEES PAID:
>. relating to building mmtruction,and hereby authorize representatives of this
1— Z city to enter a Pon the above-mentioned property for inspection pu rposes. ALT'4RORADDTLIMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date `Regal t#
V ,galeas llabllitin,' dgments,mYaand expenses which may to anywayaceme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
apayut f the granting of this Terme.
Airy m ascus;ob-�51lb AIRHANDUNG UNIT(OVER IQODOCFM) CONSTRUCTION TAX II �
Sigmturcof Applicant/Contractor Data EXHAUST HOOD(W/DI1Cn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe
a.defined
applicant the ure budding occupantodle, hapten le 9.17,.rdous HEATING UMT(TO 100,0000N) Date RCCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
He❑alt Varu[SafetyCexlc Sc&ioon2SS32(a)7 HEATING UNIT(OVER 100,000 ITLB TOTAL: _ TV
Will the applies rat Ato.
building occupant use equipment or d evices VENTILATION PAN(SINGLE REBID) ISSAMUIATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Managementst ct2 BOILER-COMP 0HPOR 1!0,000 BTU)
4hYea o JUN 1 5199'3
avercadth.Ith o&yC.dcabrequlremenb5533.Chapter 2g34.,95 of BOILER-COMP(OVER 100,000 BTU)
theersta dt Health building
Cade,Sections75505,ve a t and25574. I
understand that notify
the occupant of notcurrentlyhaves tenant,that It boy NEW RESIDENTIAL MECH. sQ.FT.
responsibility to n°U(y theomupant of/he requirements which most be met {
p' riots ante aCerlifeateofOccupancy. say OLtlnO
4 Ca eCP sed
Ov1nc ors prized agent Data TOTAL: ISSUED BY:�'41 k Cli
OFFICE COPY