19726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building I'Wer,identification PFRMITNO.
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hu r 3Jbm uls ��—Sq�pZ CITY OF CUPERTNO-BUILDINGDIVISION G
�. c rt r.Na / Jy/p,N/p APPLICATION / PERMIT
QS V �n a/ BUILDING.UFCTRICAT PLUMBINGMECIIAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.Nm
QTY ELECTRIC PERMIT F BUILDING PERMIT INFO
Address:
PERMITISSUANCE 1:1 ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby
affirm that l Boomed under provisions ofChapter 9(mmmmAPPLIANCESRESIDEN7lAL JOB DESCRIPTION
Ingwth5ect1on7000)of Divelon3oftheBµlnessand Pro(ssionsCode,
and my
LicenEL
se lei (u and dfeci. I// Z/. PANS la
Date Contactor Z9 UP TO 2D)AhTq
ptlODOAMPS
ARCHITECT' E LARATION' J
ntO Zp I understand my plans @hall be used Be public records. OVER IOW AMT'S SQ.FT.FLOOR AREA S/SQ.Fr.
hi 0 0 Licensed Professional SIGNS ELECTRICAL+
<<� OWNER-BUILDER DECLARATION g[+ECTAL CIRCUIT/
Iherebyaffirmthal lam exempt from the C mram'sLicense law for the
following reason.(Section 7071.5,Business and Professions Code:Any city or
O F@ TEMP.MFFMOR EINST.
F� muntywhichmquimapermitmmnstmd,alter,impmvedemollah,ormper
any structure priarta lb Wuance,also rcquireathe applfontfm@uch pertNt to POWER DEVI
file a signed statement that he Is licensed pursuant to the proWlons of the
O w Contractor'@ License Law(Chapter 9(commencing with Section 7000)of Divl-
�OS slon3ofthe Budnessand ProfesslonsCol0orthat he is exempt therefemeA SWIMMIN LELECIRIC VALUATION
<, the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLE SWITCHES FOC1URFS
appUmer fora permit subjects the applicant to a civil penalty of net more than
.fivehundreddo1lars(f500). NE DENTIAL ELEC'IR SQFf. SI'OWIS TYPE CONSTRIK'1'ION
�n ❑L as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is net intended or offered for
O sate(Sec.7064,Business and Professions Code:The Contactor.License Law
$� does not apply to an owner of property who builds or improves thereon,Bud OCC.GROUP RES,UNITS
EE whodaesauchwarkhin tforthr ghhlsownemployees,pr IdMthatach
improvements are not Intended reoffered for safe.IL however,thebulldingor TOTAL:
impmvement bsold within muyearofcompl&Wm theowner-bu0derwill have
the burden of proving that hedidnmbuildorlmpmveforpurpmeofsak.). QTY. PLUMBING PERMIT FEE FLOOD WNE APN
L as owner of the property,am exclusively mntractlng with licensed
rontnctme to construct the project(See.7040 Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who ALTER-DRAIN h YENT'•WATER BEA)
—
buBda or Improves thereon,and who contracts fee such plufect,with a FEE SUMMARY
�B[actoKe)Bcemd pursuant ro the Cantnctore License Law.
y•...,; L,J I am exempt under Sec B h P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
Owner - Data DRAINS-FLOOR ROOF,AREA,CO SANITARY RECEIFT If
WORKMAN COMPENSATION DECLARATIONS
PER TRAP SCHOOL TAX Y N
[:]Iceflo
I hereby affirm that I have a rtlte self-Imre,,
of consent to ora FDiTuRER_ TPT#
certllioteo(Workers•'Campero onlmur morramAiffeeld eopythereof(Sec. GAS FA.SYSCFM-1 INCA ECS PARK FEE Y_ N_
X00,Lpb C.) _Lt7C�—a�Q J9'R r/ RECEIPT#
'CAI(A—x7���I` CAS EA.SYSTEM-0VE 4(EA)
Com anv BUILDING DIVISION FEES
�Certlfied copy is hembylfumished. GRFA9H/INDUSIR ASTE INTERCEPTOR PLANCHECK FEE
4Certified copy b filed with the city inspection division.
7^[ CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SA ARY-STORM EA, Date Recel t#
RLlexction need not be completed if the permit<,(aro h red dollars
(f100)or leas.) WATER .PFR W/VINT/EL[CIR ENERGY FEE Y N
Imrtifythatlntheperformanmofthewmkforw h pe tis blued,
Ishall not employ any person to any manner n as me bleat to the WA SYSTEM/TRIATING
Workers'Compenntion Laws of California.Dat PAID
Pv SQFp, Date Recei t#
Applicant
li Z 0 NO7TCETOAPPLICktotheaRer makl his a lot Ex he L.ou RESIDENTIAL PLMB.
sode,yo mustf bjectmtcomG FEE
p 'c pro p to nhel.abbe TOTAL:
N „ Code,you must forthwith comp t u pro ort bpermlt shill be
jdeemed revoked. BU _
LU 1] CON RUC N LwDI>c A CY SEISMIC FEE
I hereby affirm that the construction mho egencyforthep.6mm, ELECTRIC FEE
Z ance rfthe work forwhlch thleperoutisbace (Sec.3097,CIv.C.) TOTAL:
U O Lenders Name PLUMBING FEE
LL F Lceder.Addrcn QTY. MECHANICAL PER FEE MECHANICAL FEE . 0U
OW I renifythat l have mad t isapplicatlonand atatethat[heaboveln(omutlon
(1 bcomect.lagreetocmnplywith allcityand cosetymoRnanreeand state laws PERMCCISSUANCE �� t FEES PAID:
} relating to building construction,and herebyauthode reprowntativesofthis
f Z cityto enteruponthe above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Reeei f#
(We)agree to @ave,Indemnify an d keep harmless the City of Cupertino
V
against liabilities,judgments,mstsand expenses which may In anywayacnue AIR HANDLING UNIT CID 10,000 CFM) SUBTOTAL: .0
against 1 iyU consequence at the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Signatuno Apphcant/Contractor Data EXHAT75'C HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBontor(.Wm building arupantetore or handle hanrdous HEATING UNIT OO I00,OJ0 BTU) , Date Recei t#
material as defiimd by the Cupertino Municipal Code,Chapter 9.1 Z and the
Health and Safety Cede Sed[M 1531(1)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
11L OP—
❑Yca ur VENTILATION PAN lBINGLF.RFSID)
Wlllthe ePpEcxmu tum building oavpam use equipment or devise ISSUANCE DATE
which rout hanrdous air contaminants as defined by the Bay Area Air
1 Quality Management District? BOILER-COMPOHPOR 100,000 BTU) PAID,
11 Q Yn �No
haza
I u"mad the rusmetenab requirements underChapler6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 2550.5,25533 and 15536. I aa( j , r 1990
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to next lfy the oaupant of the requiremdue which at be met
price to Issuance of a Cedifiote of Ocu panty, city of Cgpeff'4@
Owner or authmixed agent Date ISSUED BY: to tnv c
'TOTAL:
OFFICE COPY
all. _