20525 APPLICANT'TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY'
Building Project Identification , I'LSthRT NO.
Building Address: - ^O 5^5
G G
sera area: one:
L.D/ tCGY—r Prr-s'rJ 7.. CITY OP CUPERTIN0.BUILDING DIVISION :• �7I
LiaN APPLICATION /PERMIT-
GOJ•L2�.J - Cl2 Sb�o BUR.DINGEI,FGTRICAUPLUMBING-M1GIiAMCAL' CATEGORY CONTROLR
Architect/Engimer. - Lic.No: -
QTY . ELECTRICPERIvII'T FEE p BUILDING PERMIT INFO` • -
Atldren: PERMITISSUANCE
' LICENSED CONTRACTOR'S DECLARATION - ] D E] +
Thereby 11 hat l am licensed under previsions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL - - JOB DESCRB'7TON
Ingwlth Sect1on7000)ofDlvldon 3 ofthe Businessand ProlonionsCods,and my
license Is In full force and died. . _ PANELS - �� D� e
License Class g Lk.# fou z 10
Dale Contractor_ 1.
ARCHITECT'S DECLARATION 301-1000 AMPS '
ra ' OVER1000AMPS FT.FLOOR AREA .
OZp' ]underetand mypiano shag be used espublic ceroids SQ. S/SQ.FT.
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCR4CUIT/MISC
t 'I herebyatflrenthafrom the I am exempt frothe Contractor's License Law for the
o -following reason.(Section 7031.5,Business and Predestinate Code:Any city or
O
0 .county which requires a permit to commood,alkr,Improve,demo0sh,or repair TEMP.METERORPOLE INST.
any structure prior to lb issuance,also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
µ Contractor's License 3Gw(Chapter9(mmmencingwith Sedbn7000)ofDivi-
0 . sian3ofthe Busineeaand Profmi6.Code)orthathekemmpttherefmmand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any pzuxx - -
< appH..t for a permit subjects the applicant to a civil penalty of not more than OUT'LEIS-SWITCHFSFIXTURES- 5a 4..�ds 00
flue hundred ddlare(5500), fl
�n ❑1,as owner of the property,or my employers with wages as t U so1P " + -W �'�'' STORIES TYPE CONSTRUCTION
rompeneatlon,will do the work,and the structure is not Intended or offered for
�- sok(Sec 7044,Business and Protassions Code:The Contractor's Lim*Law
S$ don not apply to en owner of property who builds or improves thereon,and „ ! , `V� - OCC.GROUP RFS.UMTS
whodoeasuchwerkhi.lf rthr°ughhisownempleyen,providedthateuch /
Improvements are not Intended oroffered forsale.R,however,thebulldl�g5 _
improvementlssddwithinomyearofcwnpldbNtheowner-bu0derwill Mfia
1fIL�urden of proving that he did not build or improve for purpbee of main.). 01.1 MI 'FEE pl-Opp 7pNE ApN
L f L as owner of the property,am exclusively contracting with llnnwd PERMIT ISSUANCE
rontractua to ronstrud theproject(Sec.7644;Business and Professions Code:
The Contractor.Llmme Law don nor apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
builds or improves thereon, and who mntnds for such;In jells - -with S _
c LJ
admit)licensed pursuant to the Contractor's License Law. - - FEE SUMMARY
I am exempt under Sec. B&P C (or thio reason BACK FLOW PROTECT.DEVICE iOUTSIDE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY ,.. Y_ N_
Owner ES
Date _ RECEIPT N
V, WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP " SCHOOL TAX Y_ N_
$QI hereby affirm that I have a certltkate of concent to pythemof ora - RECEIPT R
certRWte of Workere''Cpompevationlneuranm oracekl(kd mpythereo((&c. -
CASEA.SYSTEM-I INCAOUTLE1SPARK FEE Y_ N— r
RECEIFT p
C .
.I1cy N GAS- ER 4(PA)EA.SYSTW-OV
' - Comm 'BUILDING DIVISION FEES
Certified mpybfiled withh tshe
cert) ed copy is here6ytd. GREASRANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
the cicityinspection division. � � - I
CERTIFICATE OF EXEMPTION FROM WORKERS' ", GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANDARY-STORM EA 200FT Date Re(X!f t#
(rhla section need mad be completed if the permit is(Drone hundred dollars
(5100)aless.) ' WATER HEATER W/VENT/HI.ECTT2
mENERGY FEE Y N
I certifythat in the perfmove m of the work forwhich this permit is issued : —
I shall not employ any person in any metwer so n to become subject to the WATLR SYSTEM/TREATING
Wmlierenma
'Competion Lemmf CalBonia..Date PAID
O Z Applicant - , - NEW RESIDENTIAL PLMB. SI Date Remi t# I
Z O NOTICE TO APPLICANT.If,a(ser making this Certificate of Exemption,you
Hshould become,tubjed to the Workere'Compensation provislonsofthe Labor TOTAL:- -
CC N Cods,you at forthwith comply with such provlslons or this permltahall be U TNG I HCl
deemed revoked.
LU
C• ' • CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Iherebyat6rmthat there is a construction lendingagency for the perform ELECTRIC FEE
L) Z ' an.ofthe work for which this permit is issued(See.3097,Civ.C.) 'TOTAL:
(� O Lender.Name PLUMBING FEE
LL I— Lender's Address qTY. MECHANICAL PERMIT FEE ' MECHANICAL FEE -
O 1 certify that I have read this application and date that the above Information
C'.W remrred.I agree to comply with all city and county ordinance and slate lawn PERMIT ISSUANCE FEES PAID: -
� In relating to building construction,and hereby authorize representatives of this
(— 2 city,to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Reeet#, '
— (We)agree to save,Indemnily an d keep harmss 1lethe City of Cupertino - P
against liabilities,judgments,"a and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit. -
AIR HANDLING UNIT(OVER 10,M0CFhD CONSTRUCTION TAX
.Signatureof Applicant/Contractor Data EXHAUST HOOD(W/DUCTS CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE- -
Willtheapplicantorfuturebuildingoccupantstoreorhandlehazardous HEATING UNIT(TO 100,00 BTI]) _
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Date Rete[ t# -
Health and Safe yCode Section 2S333(a)t EIFATING UNIT(OVER 100,000 BTU) TOTAL:
I—I Yes No .
111 the applicant ca building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DA'Z'E
which emit hatmedous air contaminants as defined by the Bay Area Air - - -
Quality Management Uslnd7 - BOILER-CAMP DHI'DR 100,IX0 BTU)
4Yee nNo a'EB✓f91
haveread the haza'r�ousmaterialsrequirements under Cho pler695of BOILER-COMP(OVER 1000DO BTU)
the California Health k Safety Code,Sections 25505,75533 and 25534.1, ,r .
understand that lithe building does not earrenlly have a tenant,that it is U
my NEWRESIDENTIALMECH? SQ.FT 't 0 ,
i`j b `99
responslblldy to ify the the requircmentawhmh most be met a,l , .
p' rro Lbs Days 1 of c panty: "
wer or author cad agent Daze,. ISSUED
OnBY:
TOTAL:
OFFICE COPY