21995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed IdentificationPERMITNO.
Budding Add mss: 6 we—c�.DR - 21995
nets ante. one:
A
71LIA _F
CITY OF CUPERTIN0.8UILDING DIVISION _Q
LIeNo: APPLICATION I PERMIT
9N C0. BUILDING-ELFCTRICAL-PLUMBING-ME LAICAL CATEGORY CONTAOLp
reMtect/ glneer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
.. Addrese: m Ice. S.� PERM TISSUANCE ❑ :1 ❑' _
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL ]OB DESCRR•TION
ingwith Sedion7000)of Divlsim3ofthe Buslnessand PmfeskmeCode,and my I
license bin full and eff,R �Gy_ tLu
�LlcenseC Lic
on D Confrador' 1 GARCHITECT`S DECLARATION V—pO I understand my plans shall be used a public records. P5 SQ.FT.FLOOR AREA $/SQ.IPL
� Licensed Professional ICAL -
6 OWNER•BUILDER DECLARATION [T/MISTt,�7 I herebyaNrm that I am exempt fromthe Contractor's License Law forthefollowing meant.(Section 7031.5,Business and Professions Code:Any city orOR POLE INST.
Vit' county which requires a permit m construct,alter,Improve,demolish,or repair
H
-file
prior to lm Wuance,aleo requires theappbunt torauch permit to ppyyER DEVICES
E5 rNG 16 file a signed statement that M b licensed pursuant to the provisions of the - ,
Q6 3 O tr, Contractor`.License Law(Chapter 9(cc.hcing with S ctxm 7000)of Divi- SWIMMING POOL ELECTRIC
ei..3ofthe Bus ftsmdProfemlom Code)orthatheisemmptthemfmmandVA�Iq,UAno (�
' the basis for the alleged exemption. Any violation of Section 7m1.5 by any OUTLETS-SWITCHES-FIXTURESU' (/
G applicant for a permit subjects the applicant to a civil penalty of not more than
live 1,a.m dolhn($S ro NEWRESIDENTIALELECTR STORIES - TYPE CONSTRUCTION
�n ❑6..owner at the property,or my employees with wages r offered
sole for �'FT'
c.m(Sec.744,Buldothaworkcleado Codurebnot Intended oroffered(or
O dile(Sec.apply
to alnan owand f property Code:The Contractor,Lianas Law
does r3$ whodoessuch torklumero(propertywho Wllds mpoNmproovided eoMand OCC.CROUP RES.UNITS
whoovementsa orkhlmae intended
hisowne.If,ho eq providedthatoucr
improvements ithin on, ear.frempletile.If,omen-q deer iii have TOTAL:
improvement lesold withinoneyearo(comp]etlon,the owner-bu0derw111 have
thW.kurden of proving that he did net build or Improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the projed(Sec.7066,Business and Professions Code: -
The Contractors License Law does not apply to an owner of property who /yTEE DRAIN k VENT WATER(EA) ,
build. or Improves thereon,and who contracts for such ptojecb with a
cgn(racher(.)licensed pursuant to Ne Contractor's License Law. FEB SUMMARY
LJ I am exempt under See' B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
OwnerDRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date.
WORKMANRECEIPT p COMPENSATION DECLARATION QFIXTURES PER TRAP SCHOOL TAX Y_ N_I hereby affirm that I have a cenitleate of consent to self-Insure,or RECEIPT p
380LIAbC.Workers'CompensaHanlnsurancearacertl(led copythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLEl'S PARKFEE Y_ N
3800,Lab C.) '
`
PA
p RECEIPT p
Com nv_ GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
DgCertified ropy b here th the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertRled ropy b filed with the city Inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 200FT - Date Recei t#
(f mlieslon need not be completed lithe permit bfor one huntlred dollen
(St I mmfessd WATER HEATER W/VENT/ELEC.I.R ENERGY FEE Y N_ .
]cent thatlnshe person
performance tmnnerhe week so
to become
h this esub)rmit is booed.
I ork not employ any.Laws in any manner se u to become subject to the WATER SYSTEM/TREATING
Workere'Compensation Laws o(Cal1(omb.Date PAID
O Z Applicant
Z O NOTICETOAPPLICt tothe ori nt'Com a sationkateot Exemption,you
NEW RESIDENTIAL PLMB. SQFE Date Recei t#
Hshould become subject to Workami Compensation provisions of Labor TOTAL:
CC r`/1 Code,you mustfMhwith comply with each provisions or this permit shall be
> deeB LDiN E
med revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
]hereby a(lirmthat there b a construction lending agency for the perform
afthTOTAL; ELECTRIC FEE
Z performance oe work which thin permit b Wued(Sec.3097,Civ.C.)
u2 Lender.Name PLUMBING FEE
LL H Lendcre Address OW. MECHANICAL PERMIT FEE MECHANICAL FEE
O W .Alfythatlhavereadthieappli tbnandetatethattheahoveinlormatlon
1 coisrrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building ronstruction,and hereby authorize representatives of this
L.._Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO METH. Date Recei t#
V (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,judguynts,codsand expenses which may In anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga brat said City Inc seque t grantin otthispermit
�V - AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
tureof Ap est/ ontraetor / Dam - EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT IALS DISCLOSURE -
Willtheapplicantorfuturebuildingoaupantstoreorhandlehazardous HEATING UNIT(TO 100,W0 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the -
Health and Safety Cod a Section 25532(a)? HEATING UNIT(OVER 100p00 HTU) - TOTAL: s�D
r7 Yea No
Will the applicant Qumm building occupant use equipment or devices VENTILATION FAN[SINGLE RESID) ]SSU •�
which emit hazardous air contaminants as defined by the Bay Area AU
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) /{p r� '1(�Qt
4 Yes Roo APR gR (l?s�S'F
have read the hazy Safety
Code,Sections 25505,
bundeand 255346.95 of BO1LEIbCOMP(OVER 100,000 BT'[J)
the California Health&Safety Code,Sections 75505,25533 and T5534.I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirement°which at be met - IY4u ae6 A..Rbp;n�
prior to issuance of a Certificate of Oceupa hey.
Owneror authorved agent Date ISSUED OY:J • 1n,D
TOTAL:
OFFICE COPY ,