20881 APPLICANT TO FILL IN INFORMAI,JN WITHIN RED LINEWIM" Cf§E BALL POINT PEN UNLr
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Building Pru'ect Identification
Building Address: s ca. 20881
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APPLICATION SUHMII A
C ;?amAr� ���-�,e �f f CKU JQ 1 CITY OF CUPERTINO-BUILDING DIVISION /� _10—q0
C
cior'eN me: 1 A-• Lic.No: APPLICATION I PERMIT D
a s/G Ir-s-ta��G `•'1Ca Z�09 BUILDINGELECTRICAL-nUMBING-MECH LAICAL CATEGORY CONTROL
Architect/Engineer. LIc.No: _
QTY ELECTRIC'PfiRMIT FEE
BUILDING PERMIT INFO
Address PERMITISSI]ANCE
LICENSED CONTRACT'OR'S DECLARATION pppLIANCFSRE5IDENTIAL JOtl DCSCRBTfON
I hereby affirm that I am Ilcensed under provisions of Chapter 9(commene-
Icarse1Snfon70W)of Dlvbion3 c(the BuslassandlsrvindoneCode,and my PANELS
Licen C a fu form and dfect.rraa���.1s
Date a CoLie , t G v
Date �}ContraRor nJ
'AICHITECI'S DECLARATION siu 301-1000, M
97, I understand my plans shall be used as public records. OVER IOW AMPS �f.FT.FLOOR AREA 5/SQ.FT.
�O SIGNS ELECTRICAL
j Licensed Prvfeacbnal
<Gl'IS OWNER-RMLDER DECLARATION SPECIALCIRCUIT/MLSC
I hereb arenthatI am exempt fromthe Contractor's License Law for the
7 �� folltfi
owing ream.(Section 70315,Business and Professions Code:Anycity or TEMP.METER OR POLE INST. '
F0a muntywhich rt requim.petwmratvct,alter,impmve,dennlbh,orrepair
E ,
gggs� a anystmmmprmrtolbbsuance,abomquimstheappBantforwchper tto POWER DEVICES
r4 V file a signed statement that he Is licensed pursuant to the provisions of the
O I., Contractor's Liceme Law(Chapter 9(commencing with Scales 7009)of DWI. SWIMMING POOL ELECTRIC VALUATION
Mon 3 ofthe Business and Protessioa Code)orthat he is exempt theeefeemand
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET&SWITCHESFIXFURES OQO
nppllant fora permit subjects the applicant to a civil penalty of not morethen
five hundred dollars%50a. NEW RESIDENTIAL ELECTR__SQ.FT. STORIES TYPECONSCRIICTION
�1,as owner of the property,or my employees with wages as their sets
compensation,will do the work and the strutlum isnot Intended or offend for
qsale(Sec.7094,Business and Professions Code:The Contractors License Law
S$ does not apply to an owner of property who builds or improves thereon,and OCC CROUP RES.UNITS
whodoessuchworkhimselforthraugh Nsownemplayees,pr idedthatsoch
improvements are not Intended oroffered fonxle.If,howevepthebullding or TOTAL:
improvementbwidwithlnoneyearofcompletioNtha owner-bullderwltl have -- -
ave
tii urden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE [E-o D'/DNE WP
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to mnstrua the project(Sec.7014 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA7
heads or Improves thereon, and who contracts for such pt,"with a FEE SUMMARY
c%tactorW licensed pursuant to the Contractors License Law. BACKFLOW PROTECT.DEVICE
I am exempt under Sec. .B&P C for this mason "
DRAINS FLOOR,ROOF,AREA,CON I. SANITARY Y N_�
Lf
Owner Date RECFRrI'M
WGRIDr1AN COMPENSATION DECLARATION FUTURES- FR PTRAP SCii(70I:TA% Y_ N—
E31 hereby efflrm that I have•certi(late of consent to self-Inwre,ora RECEIPT k
ceniflareofWorkere'Compensatlonlaurana ora osmpythemof(See. GAS EA.SYSTFM-i WC40lI1LET5 PARK FEE Y_ N-
3800,
38W,Lab C.) RFLEIPT N
•
Policy If GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
CcrtlOed copy is (umlehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Ceetlfied copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP PAID
COMPENSATION INSURANCE =SEWER-SAMTARY-9MRMORM EA,3(DFT, Date RC-i tN
RM1issection need netbe completed tfthe permit b forma hundred dollar($100)o,less.) VENT/ELECTR ENERGY PEE YNI artlfy that In the performance of the work for which this permit Is Issued,1 shall not employ any person In any manner so as to become subject to theEATING PAI DWorkeriCompmsxdo.lawsofCallfomla.DateO Z Applicant PLM B._EQFf. Date Recei tilNOTICE TO APPLICANT:If,after making that Certlfiate of Exemption,youTOTAL:should beanie subject to the Workers'Compere ation proWlons of the Labor
M Code,you=atforthwith comply with such provisions or this permit shall beDING FEE
j deemed revoked.CONSTRUCTION FEE
W CONSTRUCON LENDING AGENCY
d 0 Thereby a(Omni that them bamnstanlon lending agency for the pedorrtr - TOTAL; ELECTRIC FEE
7 Z anec ofthe work for which this permit is issued&c.3097,Civ.C.) PLUMBING FEE
02 lender's Name
LL H Lender's Adana QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O W Iadlfythat l have read tMaappllationand natethatthe above Information FEES PAID:
b correct.Iagreelo eomplywith all cityand county ordirancesand state law. PERMIT ISSUANCE
} IL relating to building construction,and hereby authodim representatives ofthh,
r N city to enter upon the abova-menEmed forW Impaction ALTFRORADDTOMECH.
Z property pen for Ca purposes. Date ROCCI tic
(We)agree to save,indemnity and keep harmien the City of Cupertino AIR HANDLING UNIT(TO 10,090 GEM)
V agalns IlabNtles,ptlgments,costa sled expenses which may In any wayaame SUBTOTAL:
agar tamcu m a� ceo ha granung hopeL�� G CONSTRUCTION TAX 1� AIR HANDLING I1NT1'(OVER IO,000GEM)
Tn CONSTRUCTION TAX PAID:
igatu o(Appllant/Contracto Datc EXHADS'T HOO4(W/DUCT)
HAZARDOUS ATERIALSOISCL.OSURE RETYING UMT(N IW,000 BTU)
Will the applicant or future building compant store or handle haaardous _ Date Recei tN _
material as defined by the Cupertino Municipal Code,Chapter 933 and the TNG UMT(OVERIW,OW BTU)
I and Safety CodHGI
ctlmt 25533(a)7 TOTAL:
C] Yen No VELATION FAN(SINGLE RESID) ISSUANCE DATE
Will the a pplicanto fuNTI
ture building occupant use equipment or devices
I which emit haaardous air contaminants as defined by the Bay Area Air A.
Quality Management rin7 BOILER-COMPOHP OR 100,0M BTI-0 PAM
4Yes No
havereadthehaa us materials uirementsunderCha er6.95of BOILER-COMP(OVER]00,000 ETU)
the btifrate I/ealth&Safety Code,Sed 75505,25533 and 35939.7 ,UG 10 1990
understand that if the building does not currently have a tenant.that it is my NEW RESIDENTIAL METH. SQ.FT
responsibility to notify the copant oft requirements which oast be met t/s '
I oissusnceo(a i ateafRoo. nry. City OI CgnP[fion
xm D Lai
nero whoriud agent Date ISSUED BY:�(JL%Bal
i TOTAL:
OFFICE COPY