20605 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
8u6din Protect Idend4lratlon PERMEHNO.
Building Add � � 20605
ner e:
ams onCITY OF CUPERTINO-BUILDING DIVISION
Contmcun`.Name: u. : APPLICATION /PERMIT
2706eNaBUILDING-ELECTRICALPLUMBINC-MFGIiAMCAL CATEGORY CONTROL It
Architect/Engineer. Lle.Na;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: -IN� PERMITISSUANCE ❑ ElElLICENSED CONTRACTOR'SLA
DECRATION
Iberebyafflrm'hat l am licensed under provisions o(Chapter 9(comment, APPLIANCESRESIDENTIALJOB DFSCRB'TfON
Ingwlth Sedton70m)of DWbion3ofthe Businessand ProfeasionsCode,and my
license Ie in full force and ef(ed. PANELS
Llcmae Cla Zoic# Oa—
OateG— Cantmdor Lz
ARCHITECTS DECLARATION VLEC
MPS
pQ�reO ZpZO I understand my plans shall be used a public records. 0 AMPS SQ,FT,FLOOR AREA $/SQ,FT,
k (1 Llrensed Pmfesslonal CTRICAL
<;< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/
Z"o�4 1 hereby efBrm'hat I am exempt(romthe Contractor's License Law fee the
O Z 1.9 following reason.(Section 7RH.5,Business and Professions Code:My city or TER OR I "
P� county which rcquiresapermitbcorutmet,alter, dertnlbh,orrepair
an yetrucure priartoits Issuance,also requirmthe applicantfor such perrdttoEVICES
file a signed statement that he b licensed pursuant to the provisions of the
30� Contractor's License Law(Chapter 9(commencing with Section 7000)ofDwI-
i.,� .ion 3.f the Business and Professors Code)orthat he is exempt therefrom and (.POO CLRI VALUATION
the basis for the slfeged exemption, Any violation of Section 70315 by anyFIXTUR
applicant fora p.mdtubjecio the applicant too civil penalty do.more than
pa five hundred dollars($500). IS
AL LEC .FT.❑I,as owner of the property,or my employees with wages as their sokSTORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is nm intended or offered for
sale(Sc 7614,Business and Professim a Cade:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,andOCC.GROUP RES.UNrMwho does such work himself or through his own employees,provided that such
Improvementsare not intended orof(ered orsale.Ifhowever,theWildingorTOTAL:improvement bsoldwithlnomyearofcomplmlb tMo ner-bu0derwlli havettaekurden of proving that he did nut build or impmve(or purpose of sale.). QTy, LUMBIN PERMIT FEE FLOOD7ANE pPN
11 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7644,Business and Professions Code: 12-dO
The Contractors License Law does not apply to an owner a property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pSojecte with a
cq➢tTaern(s)Licensed pursuant to the Contractor's License Law. FEE SUMMARY
U I am exempt under Sec B &.P C for Nis reason BACK FLOW PROTECT.DEVICE
Owner DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y N
Date RECEITT N
WORKMAN COMPENSATION DECLARATION
/ ❑I hereby Orkem that I have a cediRcate of consent to copy
there. (or aSec.— PER 7Rp1' SCHOOL TAX Y N
certificate a o(Workere'Compersatlonlmurance rna certified copy thereo((Sec. RECENT N
3X Pulley
Lab C.) GAS EA.SYSTEM-1 WC.40UTLE75
Pollrypl $O I—] , PARK FEE Y N
RECEIVE
ING IN
CLimpgm /copGf Pc7 GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
a T�rtlRed copy is hereby❑ th the city e
CertNed copy b tiled with Ncity inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 20OFT Date Recei t#
(Thos section lon need not completed lithe permit is for one hundred dollars
(8100)rnfy that
WATER HEATER W/VENT'/ELECTR ENERGY FEE Y N
.Ill not that o any person
an the workmanner
so as to b co eermit sabye booed, —
I shall not employ any person in any manner ao as'.become subject to the WATER SYSTEM/TREATING
Workere'Compensatlon Laws of California.Date PAID
O Z Appllwnt
Z O NOTICE TO APPLICANT.If,after making thin Certificate of Exemption,you NEW RESIDENTIAL PLM& SQFI'. Date Recei t#
should become subject to the Workeri Compematlon provisions of the Labor FTOTAL:' fq Code,you moat fieri comply with such provbiom or permit shall be
Wj deemed revoked. BUILDINGFEE
(L C CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z ce 30
I hereby affirmehat there Is a construction lending agency forthe perform, $Lanof work for which this permit is Issued(Sec. 97,Civ.C.) TOTAL: ECTRIC FEE
'�
V O Lender.Name PLUMBING FEE p
LL H I.ender'apddreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertl(ythatl have read thisapplicatlonand statethaHheabovelnfornstlon
Q. is Mmed.I agree to comply with all city and county ordinances and Maw taws PERMIT ISSUANCE FEES PAID:
} Nreladngtobulldingoostruction,and hereby auth.mm representa'Iveaofthle
L. Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,Indemnify as d keep harmless the City of Cu pertlno Date R(:Cel Pf#
against liabilities,judgments,cousin accrue
ts and expenses which may in any way AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
Inst said City In cons no,of th anting of this permit.
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
'Signature. p cant/ContractorDate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATEAAe2SDISCLOSURE
Willtheapplicantorfulure building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
Hmaterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
ealth and Safety Cade Sedion 25532(.)7 HEATING UNIT(OVER 100,000 BTU),
❑ Yes I�I NTOTAL: ,OO
No
Will the applicant o future building occupant use equipment.,device, VENTILATION FAN(SINGLE RESID) I$SUALVffi mA+FE
which emit hazardous air contaminants as defined by the Bay Area Air lOA741�a oa i
Qu a lily Management District? BOILER-COMP OHPOR 100,0(0 BTll) \\�� q y��7
4hYes n . JUIN2, * I99U •,
ave read the th&Safety Code,
tions 25505,255underChapter 25534.15 of BOILER-COMP(OVER 1 W,000 RN)
the
erstan that
if th&'Safety Code,Sed Ems25505,ve a tenant,
25534.1
understand thatn notihe fy
the ing occupant not erently equire encs tenant,that it met NEW RESIDENTIAL MF.CH. SQ.FI.
prior to
responsibilitytonot Corti occupant requirements which moat be met G u1 to
prior to Issuance of Cemficatc of Occupancy. _ - ��i ll - ^
Owner or authorl,md agent Date ISSUED BY:
OTAL:
OFFICE COPY