20174 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
1\�
Building read: T 20174
ra
am 45� - CITY OF CUPERTINO-BUILDING DIVISION `
ContradorsName: ue.N- APPLICATION / PERMIT S� •.I�— �
�++ BUILDING-ELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lk:No:
Q'cn�.' '•ELECTkICPERhtITy ..''tFEE1"BUILD,I,NGPERMIT INFO ,
Address - PERMITISSUANCE ❑ ElLICENSED CONTRACTOR'S DECLARATION -
El
Ihereby afflan that l am licensed under provisions of Chapter 9(rommose. APPLIANC RESIDENTIAL JOB DESCRIPTION
Ingwith Section7000)ot Divislon3ofthe.Buieressand PIe resslon.Code,and my,
licenselsln fup fo defied. PANELS
License-A-L- le q S�9
Date S-1'1-qo C.rdmctor'FSAF3 � � MA Ally - - fit/IZ
ARCHITECPS DECLARATION 201400
�Oz I understand my plans shall be used as public records. OVER1 SQ.FT.FLOOR AREA S/SQ.FF.
CO
dO Licensed Professional SIGNSE L
6 OWNER-BUILDER DECLARATION SPECIALC T/MI
7p, � 1herebya(Brrothat lamexemptfromthe Contractor's License Lawforthe
oo following reason.(Section 7031.5,Buslnem and ProfesslOns Cade:Any dty or
O Z t TEMP.M OR LE IN
rou
r4 ntywhich requireea permit[oronslrud,altep improve,demo)lah,orrepalr
anystraclure pdorto its lasuance,alsorequlrestheapplicant forsuch permit to kO%VERWCFf
file a signed an,"nu,ot that he Is licensed Pursuant to the provisions of the
O w Contractors License Law(Chapter 9(commencing with Section 7000)of Divl-
� ¢� sion3ofthe Business and Professions Code)or that he is exempt therefrom and FLE VALUATION
❑ the basis for the alleged exemption. Any violation of Section 7031.5 by any O ETSSSWITCHES_ ES
eM?c applicant fora permit subjects the applicant to a civil penalty of am more than O
Ove hundred dollarshepr. - STORIES ' S TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole [DENTIA TR FF -
.1c(Se compensation,will do the work and the Code:
rch not Intended or o(femd(or
O sale(Sec,apply
to Business owner
f p ressbm who
Wilds Contractor's Uceve Law
e5$ does not apply to an owner of property who builds or Improves thereon,andOCC.CROUP RES UNITS
EEE whodoessuchw.rkhimselfonhroughhisownemployees,providedthatsuch
improvements are not Intended oroffered for sale.It howevegthe buildingor OTAL;
improvement ssold withinoneyearofcompIdt6o theowner-bu0derwRl have 7 ,,
ttle�urden of proving that he did rwtbulld orimproveforpurpossofeak) (2Ty, .';'i pI I7MBING.PERMIT E"'
u FLOOD ZDNE APN
I,"as owner of the property, Se exclusively044,Bsi contracting with licensed PERMIT ISSUANCE
contractors to ronsirvd the w doe(Sec.apply
Business and Professions Code: -
The Contractor's improves
License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such pinpcta with a
➢➢__t[[act'mereason
to the Contractor's Llcenee Law.
OUTS I,.tFEE'.SUEFSEIS '
LJ I am exempt under Sec. B &P C icer this on BAFLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
'. Owner are RECEI'Tp
WORKMAN COMPENSATION DECLARATION FIXTURES PER 7'RM SCHOOL TAK Y_ N_
[hereby afflrtn that I have a certificate of coven to self-Insure„ore
certificate m Workers'Compematlon lvuranmara codifiedRECEIPT#copythereof(Sec.
3800Lab C.) GAS EA.SYS'I'EM-11NC,4OUTLETS PARK FEE Y N
.
Policy# WC;G �1'Ofo?7,NeCAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
- RECEIPT#
Com any Pt,RrnQ. A7 ht-�[a NVQ f_.-
[Certified copy is heed adth the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Ce'riRied ropy le filed Mth the city Inspection divbion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINERSAMTARY-STORM EA.200FT. Date Recei t#
. (IhissectlOn need am not be be completed lithe permit is(or one hundred dollars
($100)or leas.). WATERHPKTERW/VENT/ELEC'TR ENERGY FEE Y N_
I certifythaf in the performance of the work forwhich this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSIFM/TREATING
Workem'Compensation Lawsof Califomla.Date - PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
should become subject to the Workers'Compensation provisions of the Labor - TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be - LDING
j deemed revoked. FEE
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there le a construction lending agency forthe perform ELEGTRIG FEE
Z an.of the work(or which this permit is Issued(See.3097,Civ.C.) TOTAL '
02- Lender's Name
PLUMBINGFEE
U. F Lender's Address QTY. M$CIIANICAL PERMIT FEE. ? MECHANICAL FEE
OW Icertilythat l have read thisappllcodonand stamthatthegawn Information
a Is COmed.I agree to comPlywithall dtyand rountyordinances and state laws PERMITLSSUANCE FEES PAID:
} N relating tubuildingcovtmctlon,and hereby authorize representatives alibis ,
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
V . Me)agree to save,indemnity and keep harmless the City of Cupertino - Date Receipt#
againstliabillties,judgments,costsandexpenseswhlchmaylnanywayamme AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
ag9irpt said Ity In cons�fea4e oft ening o(thle permit. PIR HANDLING UNIT(OVER I0,000 CTM) CONSTRUCTION TAX
III`natum Contraf to CONSTRUCTION TAX PAID:
Signa[ureof Applicant/Contracidr - Date. EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS OI SCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Sect Ivi 25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL: '
❑Yes TN-
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management
4haereadthehazDa BOILER-COMP(31IPOR100,000BTU)
� d.,erialsrequimensunderChapter6.95of BOLER-COMP(OVER 100,000 BTU)' PAID
the California Health&Safety Code,Sed ions 25505,25533 and 25534.1 qry n
understand that lithe building does not currently have a tenant,that It le my NEW RESIDENTIAL MECH. SQ.FT. MAY '�.. �, IJJ�
responsibility to notitythe occupant of the requirements which must be met l
'Prix issuance of
Cert t of Oc
yp �
YLb'Fexed `Gf'i!/wee 5-� 7-�lc� �� LAS Y 79 X mer
Owner or authorized agent - Date -
' TOTAL: ISSUED BY
s
OFFICE COPY