20857 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Proem Identification PERMIT NO.
Building Address:
J8^V1/1 O n r
G
case ams: - one:
UT CITY OF CUPERTIN0.BUILDING DIVISION
c°^°co aesName: ua.Nnn APPLICATION / PERMIT U 1
BU)LDINGE.ECTRICALPLUMBINCMECIIAMCAL CATF.CARY CONTROL M
A hitect/ gl,uer, Lie.No:
O O-
QTY ELECCRICPERMIT FEE BUILDING PERMIT INFO
Add.,: PEMTISSUANCE ❑ a ❑
LICENSED COamed under
pr DECLARATION
Iherebyion7OOO)ofDt llemsedhe Bug viand Pm Cssims9(mmmmc APPEANCESRESIDE L JOB DESCRIPTION
ingweh Sen ion force
efeon3o(Ihe Businnsand Professions Code,and my ��` �
LI.. le In fug forte and diem. PANELS
License Class Rte- Lie. dj'? Piss']
Date _["--3/-S/ CoMnnor NA TH,G--A-'/ ,
ARCHITECTS DECLARATION 201'1 75
EO?etO ZZ I understand my plana aballbe used ss public records. DYER 1 PS SQ,FT.FLOOR AREA $/SQ.FC.
66(/ Licensed Professional SIGNSE 1, -
<t OWNER-BUILDER DECLARATION L T/
Zs, Thereby a/arm lbat lam exempt fromlhe Contndore License Law for the
p following reason.(Section 7031,5,Business and Professions Code:Any city or
0 4 TEMP. OR E I ST.
FE awshocturh requlresa penance,coutmn,alteheaprovent fors ch,ermitto
g any atwmure palerto ent Wt he
licensed
pursuant to the rovisihparmWe
C5 O Ilea signed statement that he t r9(co pursuant it the tion 70oru f the
Q6 Contnnor'a LkerueLaw(Chapter9(mmmennng with Section 7f100)o/Diet.
�OQ slon3ofthe Business and ProfenimuCodOmthat hell exempttheretmmand NC LEd.E C VALUATION
<� the bash(or the alleged exemption. Any violation of Section 70315 by any q0JqE.� .� V r'a•x�a Q" L.%•'
applicant fora permit subjenatheapplicant to a civil penalty of not more than lJ VV
flue hundred dollars r. W RESIDENTIAL L SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the
he pproperty,or r employees with wage as thele rule -
romperuatlon,w0ldothework endthes/nmure la esus Intended or offered for
psale(Sec.7094,Business and Professions Cade:The Contractor's License Law
$$ don not apply to an owner of property who builds of improves thereon,and OCC.GROUIP RFS.UNITS
whodooa euchworkhimeelforthr°ughhlsownemploym providedthatwch
improvement,are not Intended oroffered foraate.1(h°wevey thebuilding or TOTAL:
improvement taxed within oneyearo(compimimn,theowner-buBderwlll have
tryRtlurden of proving that he dol not build or improve for purpose of sale.)., QTY,I PLUMBINGPERMIT FEE FLOOD ZONE APN
L L as owner of the property,am exclusively contracting with licensed PpRMpp ISSUANCE -
contractors to construct the pm)ed(Sec.70K Business and Professions Code:
The Consomme,License Law don nor apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
build. 0,improves re
theon,and who contracts for such piujems - -
with a FEE SUMMARY
cge}pmor(s)Ilansed pursuant to the Contractor's Limnm Law. BACK ROW PROTECT.
LI I am exempt under Sec B 4 P C for this reawn
Owner Data
DRAINSI-LOOP.ROOF,AREA,COND. SANITARY Y_ N_
RELEPT M
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCITOOL TAX Y_ N_
[hereby af(Irm that I have a certificate of consent to ul!-loom,or a RFC®•F I
38M,Lab of Workers'CompevaBonlnurance ma certified copythemo((Sec. CAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
3500,lab C.I RECEIPT N
Polkyp - CAS -0VER9(EA)
Com any BUILDING DIVISION FEES
CortlRed ropy is hereby furnished. CREASE/1NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Certlfod copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEWER -STORM F.A.200Ff. Date Recei tri 71h�
(Thl,sedimn need not M complded If the pemdt la forom hundred dollars
(4100)orlts.)
.EC '
I certifyeh in the performanceperformance
ounce o(the work forwhich this permit Is issued, WATER HEATER W/VENT/ETR ENERGY FEE Y N
1 shall net employ any person in any manner n as to became subject to the WATERSYSTEM/TREATING
Workers'Compensation law,of Califomla.Date - PAID
Applicant Date Rerni tp
Z NOTICE TO APPLICANT.ILafter making this Certificate of Exemption,you NEW RESIDENTIAL PLMB, SQFf.
Fshmldbecomasubjodtothe Worken'CmmpenatWnprovblamofthe Labor TOTAL:
N
Cods,you=at forthwith comply with such provisions orthis permit shall be BUILDING FEE
a�
W j droned revoked.
a c CONSTRUCTION I.a ON LENDING AGENCY SEISMIC FEE 9
Ihercby aork for ttherebacoretndionkndse. ag7,Civ. the perfomf TOTAL: ELECTRIC FEE
0 Z ancemlthe work for which this permit blssued(Bee.3097,CIv.CO
00 I<nderi Name PLUMBING FEE
LL e Lender',Addw QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I wrlifythatl have read thisapinformationti°nand statethal theabove information
C 13comea.Iagreet°c°mplywith all cityand countymrdloaern and state laws PERMIT ISSUANCE FEES PAID'.
>. relmingtobulldlogeomtrudi°n,and herebyauthorize mprewntativesmfthia
F N dty to enter upon the above-mentbncd property up
for besion purposes. ALTERORADDTOMECH.
Z Date Recei tH
(We)agree to saw,Indemnity and keep harmless the City of Cupertino
V
against judgments,cosrsjand expenses which ma In an w aaxue AIR HANDLING IJMT(TO 10,000 CFM)g t y Ir co -✓J B :.y Ila i SUBTOTAL:
If alnsl old Cl in roes emxo the ant o(thla oral
�' 4,4 AIR HANDLING UNIT(OVER Io,BBBCFM3 CONSTRUCTION TAX .
Signature of Applicent/Contractor Data DCHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Wllltheapplicantorfuture building occupant store or handle hazardous HEAITNG UNIT(TO 100,000 IT1p Date Recei ttf
material as defined by the Cu penin°Municipal Code,Chapter 9.12,and the
I lea lth and Safety Code Icon 2S532(a)I HEATING UNIT(OVER 100,000 BM TOTAL: 0
❑Yea Nm
m VENTILATION PAN(SINGLE RESID)
Willlhn uirerd. °rr rebuilding occupant, allosy equipment or devices ISSUANCE DATE
whkhemithazanfowalrcontaminnnb as defined by the Bay Area Air
Qua lity MavgementD rid? BOILER-COMP OFN OR 100,000BM '1
Yee
anmous mctyC slob re..25SOnb5533.nhapter. 1 mf BOILER-COMP(OVER 100,000gM PAJX)'
the Cstand taHcatthk9a(ety Code,net
have
a Land that it
Pd918.1
understand that If the building don net corrently Faveatenan4 that it L+my NEW RESIDENTIAL MEGA. SQ.FT. ,
responsibility to not dy the occupant of the requlr menta whi tbemet , , 77 / (�6;I ,
prior to issuance cfa Certificate of sampan iy9L1 (_
Ownerorauthorized agent Data ISSUED•&yr\7J
• TOTAL:
OFFICE COPY