19872 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proedldenllflutlon PERMITNO.
Building AAddress: I e0 � 0 19872
wners aces: _ mm:
CITY OF CUPERTINO-BUILDING DIVISION _
tnctore a LIc.Na APPLICATION /PERMIT
U(j Z BUILDINGELECTRICA PLUMBING.MECHANICAL CATEGORY CONTROL N.
ItM/Engfinei: Lk.No: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcsc 206 r � PERMITISSUANCE El El El
CONTRACTOR'S DECLARATION
Iherebydfi70that lam Bcen3oftheerp saansof ChapteC(e,and API'LIANCESRESIDENTIAL JOB DESC O
In ease is ection jyme and
diedn3o(the Buanessand7arofesslonsCode,and my
license Is In mB pro and dfat. / PANELS '
LI«nee Class L k-M rSZ
Dale a Codractor
ARCHITECT ECLARATION ZOI-1000 AMT'S
OcaV Zp I understand my plans shall be used as public moartls OVER 1000 AMT'S SQ.Fr.FLOOR AREA 5/SQ.Fr.
quLicensed Professional. SIGNS ELECTRICA
G 61 W OWNER-BUILDER DECLARATION SPECIALCIRCUIT/
I hereby affirm thatI am exempt from the Contractor's License Law for the
Q 202020p fallowing reason.(Section 70'31S,Business a nal Professinre Code:Any city or
�z cauntywhlchmquiresaper ttommtmd,alter,impmwdemolbh,ormpair TEMP.MEFFROR POL I Sr.
q� anystm=mprimtoibi=ance,alaorequirestheappbmntfmsuchpor tto POW,ERD CES /
PJ file a signed statement that he is licensed pursuant to the provisions of the
063µG Contactor.License IA.(Chapter9(commencing with Section 70DD)of Divi- gW�BtiMgN LELE VALUATION
eon3ofthellusines...d Pmfmg..Code)orthat helsexempttherefromand /
a the basis for the alleged exemption. Any violation of Section 70315 by my OUTLETS H� NK
applicantdaom tha
applicant for a permit subjectsthe applicant to a civil penalty nmn (p
five hundred dollars ISM, NEWRESIDENjVLTWTR STORIES TYPECONSTRUCTION
�n
ME,..owner of the property,or my employees with wages as their sole
compensation,willdothe work andthestruclure isnot intended or offered for
❑ sale(See.7044,Business and Professions Code:The Contractors License law
;S does not apply to an owner of property who Wilde or improves thereon,and - OCC.GROUP RES UMTS
EE who doessuch work himself or through We own employees,provided that such
Improvements are not intended or offered for Ole.If,however,the building or TOTAL:
Impnevemenalasold withlnaneyearofem pldio4theowner-Wllderwillhave '
thLIlumic.of proving that he did na Wild or Improve for purpose of In.). QTY, PL I 19B-IN GP MIT FEE
as owner of the property,am exclusivelye contracting with licensed FLOOD ZONE APN
PERMITI.'SUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: .
The,Correctors License law does nor apply to an owner of property who
Wilds or Improves therm ,and who contacts for such pkojeds with a ALTER-DRAIN&VENT-WATER(EA)
cgBilader(s)Ikerued pursuant to the Contractor's License Law. FEE SUMMARY
LI[am exempt under Sec B&P C for this reason BACK FLAW PROTECT.DEVICE OUTSIDFFIIES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT p
WORKMANCOMPENSATIONDECLARATION❑ FIX7URES .gyp SCHOOLTAX Y_ N_I hereby affirm that I have a certificate of consent to self-insure,ce
K
adlRare en'
o(WorkComgxnatlonlmunnce ora artlfle copy thereol�cc. RECEWTGAS EA,9YSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Isis CJ p�
Polirys [[�r 2 9 3 GAS F.A.SYSTEM-OVER DINGRECEIDIVISION
Com BUILDING DIVISION FEES
�Certifidcopylahercby fuMshe. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy la filed with the city inspection division.
CERTIFICATE OF EkW"ION FROM WOR KERS' GREASE7RAP PAID —
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20071• Date Revel ted
(This section need nor be completed if the permit la for one hund red dollars
($100)m less.) ENERGY FEE Y NWATER HEATER W/VENT/ELFCTR
I artifythat m the performance of thework forwhlch this permit is Issued,
I shall note toy any person In any manner so O to become subject to the WATER SYSTEM/TREATING
Works:c vein oSCaummla.Dae PAID
O Z Applicant a/r.s�ea NEW BE PLMB. SQ.FT. Date Recef ted
Z O NOTICETO APPLICANT.:IL after maldn hla CertBkateof Exemptkn,you
should beams subject to the Workers'Compa ualon provisions of the Labor TOTAL:
ItN Code,you=atforthwith comply with such provisions mthls permit shall be I N
W
> deemed revoked.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihercbyaffirm that there la a construction lending agency for the perform- ELECTRIC FEE
Z ance of the Lerula .Nwork(or which this permitb Issued(Sec 3097,Civ.CJ
TOTAL:
V O I<ndera Name - PLUMBING FEE
IL 1— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certilythatl have read this application and aatethattheabove information
IL Is correct.I agree to comply with all :
city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID
>. relating mbulldmg corstruction,and herebyauthorlu mpmtativesofthla
I.. N city to enter upon the above-mentioned property for impedbnpurposes. ALTER ORADDTO MUCH.
? (We)agree to aave,Indemnify an d keep h•rMess the City of Cupertino Date Recei ted
V agalOt Babilitlea,jadgmenla,rnaaand expenses which may in any wayacaue AIR HANDLING UNIT(TO ID,000 CFM) SUBTOTAL:
agaf�ct Old City jn consequence of the granting of this permit.
(/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SiI ttureofAppppBaaet/Contradm Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or mlum building occupant store or handle hanrdous HEATINGUMT(T0100,00011TW Date ReceI ted
material as defined by the Cupertino Municipal Code,Chapler9.IZ and the
fimith and SafetyCode Section 75532(.)7 HEATING UNIT(OVER 100,000 NEW TOTAL:
❑Yes No
WBlthe.ppllant ar urum buildingompad use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
®
which e Manage Management
air contaminants as define by the Bay Area Mr
slaty Marueardou air coos BOILER-COMP DEEP OR 100,000 BTW PAID
Yes nn No
ave read the hazardous materials requlmmints underChapter 6.95 of BOILER-COMP(OVER 100,000811)) APR 11 1990
the Callfomla Health&Safety Code,Sections 25505,25533 and 75534.1
•_� urd.t.nd that If the building dim nm currently have a tenant,that it b my NEW RESIDENTIAL MECFI. SQ1
ra Io�6Blty to notify the occupantof ccupa requirements which must he met
prio I issuance of.CeetifkateafOavhe req wU f
�T�pil.LailCr y—/D a
Owner agent Date TOTAL: ISSUED BY:
OFFICE COPY