20518 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
I V/CO IN f>I3 20518
nos ams: one; APPLICA
Lging" CITY OF CUPERTINO-BUILDING DIVISION p
Rnm e.Nana, Lm.Na. APPLICATION I PERMIT ;/P � tv
Aly
�rchl�A/E;n�Ig�in'e�er. r BUILDING Le
CATEGORY CONTROL�� L�
7 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address x'10 Pj.C/Lj PERMITISSUANCE ❑ 1:1 1:1 ElLICENSED CONTRACTOR'S DEC W RATION
Iherebyafflrmthat l amlicensed under pruvWor%cf Chapter9(commarAPPLIANCESRESIDENTLki, JOB DESCRIPTION
ing Mth Se on7DW)of Dlvltlon3ofthe Bus(neasind PmfesslmsCode,and my
It I.In s foss and died. � PANELS
Lk,e.
License Cls® Lk.N_L/r/ rILP
` 1
Dale Conm or
ARCHITECTS DECLARATION 701-1000AM
115\ Al
1QpW+�pIaZOCC I understand my plans.hall be used m public records. OVERIONI - SQ.FT.FLOOR AREA $/SQ.vr.
EZtj Licensed ProfessionalmSIGNSE TRI 1 os�
«<<<6 OWNER-BUILDER DECLARATION SPUCUL Lt-1 G /`}'{r•'N
Iherebyaflrt3allam exempt from the Contractor's License Law for the
o'aa�H following resat n.(Section 70115,Business and Professions Code:Any city or
Fpcountywhirh requires.permit toeMrucyaller,improve,demolish,orrepalr
q anystmd mpeortolbi ameabortqulmtheappUmntforsuchperMtto "DENS
f5 O file a signed statement that he Is licensed pursuant to the provisions of the
�Qj Canlrador'sLicense Law(Chapter9(commencing with Bect1an 7000)of Divi-� MI ECTRI VALUATION don3 of the Business and ProfesslonsCode)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70115 by any s .,yl
appu.t fora perMtaubjects the applicant ma civil penalty ofnot mom than O N �(�'ZO CdA
five hundred dollars($500). NE D ELECT' .FT. STORIES TYPE CONSTRUCTION
7 6 ❑I,as owner of the property,or my employees with wages as their sole
compensation,wllldothe work and the.tmdure is not Intended or offend for
q sale(Sec.7014,Busmess and Professions Cade:The Conmdofs License Taw
does notepply to an owner of propertywho Wilds orImprove.lhereoR and GROUP RFS UNITS-
improvements
does such work himself or through his own employees,provided that such
improvements am not intended proffered forsale.I(however,the buildmgor TOTAL:
improvement issoldwithin oneyearofcomplelion,the owner-bulWerwlll have
the burden of proving that he did not Wild or Improve for purpose of sale.). Q'fy, PLUMBING PERMIT FEE FLOOD TONE APN
E]L as owner of the property,am exclusively--c—,with Ilmmed pp R p CE
contractors to constad the pmjed(Sec 7014,Business and Professions Code:
The CantadaY.License law does not apply to an owner of property who
Wilde or improved therm pkojects ALTER-DRAIN h YENT-WATER(SA)
p a,and who contracts for seen with a FEE SUMMARY
cgp((ador(e)Ilreneed pursuant to the Conlradars Limnos Law, RACK FLOW PROTECT.DEVICE
{_l I am exempt under Sep B k P C for this mson
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
I Owner Date RECEIPT'k
ORgN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a certl of consent to. eure,or RECEIPT N
certi0ate o(Worken'Compeaatlonlnsumnna oracertBled copythpythereof(Sec. GAS EA.SYSTEM-I INCAOUTLETS PARK FEE Y N
RECE]BOD,lab CJ
Pollry Y_ /1,L� G sus^ DING DIN
1 CAS F.A.SYSTEM-OVER d(EA)
Com BUILDING DIVISION FEES
�CedBled copy 6 heed with
the city GREASE/INDUSPRL WASTE INTERCEPTOR PLANCHECKFEE
❑CedBled ropy bflled with the city Inspection division. ♦ —"8 p
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID 17 561 �� �� �.
COMPENSATION INSURANCE SEWER-SANITARY-STORM RA 700FT Date Recei t# )46
R)or I.on need not becompleted Ilhe permit is(Drone hundretl dollar
($lW) WATER HEATER W/VENT/171 TR ENERGY FEE -Y N
lartifythal in the pedomanceafthe work forwMNthle permit is Issued,
1 shat not employ any person m any manner w as to become wbjed to the WATER SYSTEM/TREATING /� �d� �•/ �
Workera'Compensation Laws of California. Date
PAID A'E5-[� �n�
O Z Applicant NEW RESIDENTIAL PCMB. SOFT. Date Recei t# a�
Z O NOTICE TO APPLICANT:If,after raking l his Certificate of Exemption,you
should become subject to the Workers Compercatlan provisions of the Labor TOTAL: Oti
465
N Code,you rand forthwith comply withsuch provisions or this pemit.hall beB .Ona'
W > deemed revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
M
I hereby affirmthat there is a coatmdion lending agency for the perform- TOTAL:
ELECTRIC FEE
:) W
Z ac..ftha workforwhichthis permit is Ended(Sec.3097,CIv.C.)
02 lender'.Naar PLUMBING FEE
LLI- Ienda?.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImAifythatlMwmadthlnappBalmnanddatethatlheabovelnformetlon
1 eMmed.l agmto complywith all city and county ordinance and date lawn PERMIT ISSUANCE FEES At
). W relating to building construction,and hereby authorlu representatives of this �i O
I.- In rmrrupontheabover..tJod property for bapeolon purposes. ALTER OR ADDTO MECH.
? (We)agree to save,indemnify and keep harmlesethe City of Cepedmo ate Reee) t#
V against liabilities,Hdgments,codsand expenses which may In anywayaceue AIR HANDLING UNIT lT010,000 CFM) SUBTOTAL:
ag.bal said City in..spree..of the granting ni this permit.
[� 4,1 (1 O AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
reof Appur—'tint/Aonmetor —mjtt. s EXHAUST HOOD(W/DUCT) CONSTRUCTION TAXP
HAZARDOUS MATERIALS DISCLASURE
Will the applicant or fu me Wilding occupant store or handle ha>ardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyC Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
E]Y. No
Will the applica of arta re building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) s}6SyQNCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air CM111d
Quality Management Vistridl BOILER-COMP OIIP OR I00,0M BTU)
4Yes NNO
havemad the hass srtaterialsrequirementsunderChapierG95of BOILER-COMP(OVER I00,ODOBTU) JUK4 71990
the California Health A Safety Code,Sect tons 75505,75533 and 7SS34.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the past of the requlrements which must be met • D
prlo toofa Ccniflate of Ocapanry. Y Ii
D UVAW
Ow er or aulhodud agent ate - ISR
TOTAL:
OFFICE COPY