21282 APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES - USE BALL POINT PEN ONLY
Building Proact dentlncation -
PERMIT NO.
Building Address: d y/2--F .212'8
1n8 A
wMa ame: one: l/ { - A
a44f-"96 96 WQJ4HT`zS''•7 (99/$ CITY OFCUPERTINO-BUILDINGDIVISION
Contnctor'aName: ,/ -.�Lalc..,Nyw / APPLICATION']PERMIT
G C �CiAI cl H'CI` o O o o�O BUILDINGELECTMCAI PLUMBINGMMHAMCAL - CATEGORY - _- CONTROL#
Archlted/Engineer. I uc.Na BUILDING PERMIT'INFO, •'
•,� OTY ELECTRIC PERMIT FEE -
Address: . . PERMITISSUANCE '� - ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provisoes O(Chapter 9(mmmene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith SeMon7000)of DlWaion3otlhe8uslneaandPro(esalonsCode,and my11 '
Licenlaie full force diced. 8, / PANELS - ✓CT\F\ �
License Clam Fay O
Date_a e_f.�_[e�CHITE or
�(7VARCNITECPS DE IARATION OVER00 AMPS
0Oz Iundmtand my plata atoll be and as public remide. OVER]ORO AMPS SQ.FT.FLOOR ARTA 5/SQ.FT.
PQQtq O
Licensed Professional '- SIGNS ELECTRICAL "
GGGGGG 6 t�Cl, OWNER-BUILDER DECLARATION
SPECIAL CIl2CUIT/MLSC -
Z owing ason. that l am 31.5,B from ass a Contractor's License Lay city he
or _
following reason.(ima p 70315,Business and Professions ne Code:Any city it
O�is� TEMP.METQtORPOLE ST.
0� countywhich rcqulresaperMttomrutrucL alter,improve,demoltsh,or repair ,
.c anystrodure priorto its inuance,alsorequireatheapp8rant forsuch permit to POWER DEVICES
�. file a signed statement that he It licensed pursuant to the provisions of the
�$Ow Contractor's License Law(Chapter 9(mmmeneirg with Section 7000)of Divi.
SW MM NG POOL ELE C W VALUATION
30 slon3o(the Bus eaand Prfeuiov Code)orthatheisexemptthemfmmand
O the basis for the alleged exemption."Any,vlolatlon of Section 7031S by any OUTLETSSW[TCHES �7
tuWCS] SE?1c applicant for a permit subyMtheapplicant too civil penalty of nM more than
flue hundred ownerdollar
hepr. NEW R AL EL FT, STORIES TYPE CONSTRUCTION
o ❑I,es owner will
of property,or my employees wiot th wages m thele dole
sampenat044,ion,Business workand toes Code:
eh Contractor's
orofferedfor
� sale(Sec.7044,Business and Pro(eabtu Code:The Contractole Llceme Law
$' does not apply to an owner of property who builds or improves thereon,and ,•OCC.GROL)P RIS.UNITS
www who doessuchwork himde8 orthrough hisownemployces,provldecithateucM1
improvements are not Intended orof(ered for sale.If,however,lhebulldingor
improvementissold withinoneyearofewnplelogtheowner-bu8derwslhave .1
the burden of proving that he did not build orlmprove for purpose oPoaleJ. QTy, PL, NG PERMIT FEE Ff.00D7ANE APN
F-1 I,as owner of the property,am exclusively contracting with Iicenaed PERMIT]SSU
mntrsdo.m construct the project(Sec 7044,Business and Professioru Cade:
The Contractors License law doss not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) "
builds or Improves thereon,and who contracts for such projects wit a
cgBt(ador(a)licensed pursuant to the Contractor's Lioenn Law, FEE SUMMARY
LJ I am exempt under.Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE _ QIITcf.c FEES
DRAINS FLORA ROOF,AREA,COND. + SANITARY Y N_
Owner Date 'RECEIPT 11
WORKMANCOMPENSATIONDECLARATION pIxTUREs PER TRAP SCI{CK)L TAX Y N
hereby a(flim that I have a certificate of consent to self-Insure,ora .. .. RECEIPT#
certificate ofWorkeri Compensation Insurance or acertifaled mpy[M1eteof(Sec. GAS EA.SYSTEM-]INC.4 OUTLETS - PARK FEE Y N
RECEIPT#
PolkyN O / GAS EA.SYSTEM-OVER
Com anv Q�a( BUILDING DIVISION FEES
Ce mpyV hereby(urnlshed. GREASE/INDUSTRL WASTE IN'T'ERCEPTOR PLANCHECK FEE r
_rtified mpy le Ned with the city inspection division. `.
CERTIFICATE OF EXEMPTION FROM WORKERS' • GREASE TRAP PAID
COMPENSATION INSURANCE 200F1' DRI¢ Recei tt1
('Thissedion need not be completed lithe permit Is fortune hundred dollars STORM EA _
($10))or lea.) WATER IHFATE4W/VENT/ELECTR ENERGYFEE Y N -
Icertify that Inthe performance o(the work(orwNch this pemN[le Issued,
I shall out employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING.
Workers Compereatlon Laws of Callfomla.Date '. PAID -,
O Z Applicant NEWRESIDENTTALPLMB.ySQtr. Date Recei t#
Z O NOTICE TO APPLICANT:If,after taking this Certificate of Exemption,you
should become subjectto the Workers'Compensation provisions of the Labor - TOTAL:
F CO Code,you must forthwith comply with such provisiotu or this Permit shall be a�Q
LUC deetml revoked. BUILDING E
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aNrm that there bacomtmdlon lendingagency forthe perform TOTAL: ELECTRICFEE
O ' Le of the work(of which this pemnK la Issued(Sec.3097,CIv.C.), - _
O Tender's Name PLUMBINGFEE
F Lender's Address QTY. MECHANICAL PERMIT . FEE
O W Escorted.Imrtllythatl have read thisapplimlionand statethattheaboveinformation MECHANICAL FEE
a I agmeto complywith all cityand county ordinances and state laws PERMTTLSSUANCE FEES PAID:
�. (n relating to building mmtmction,and hereb authorlae reprenntatives of this -
F Z city to enter upon the abovemention rope ped ion purposes. ALTER OR ADD TO MECH. . Rafe Receipt#
(We)agree tofndte�� keep hrr�o t City of CupertinoVagainstBabNtlea, enexpert Fhl ryin anywaya a AIR HANDLING(INTI QO10,000 CFM) SUBTOTALXinrtsald eqe r ngof permit/ ro / AIR HANDLING UNIT(OVER]O,000CFM) CONSTRUCTION TAX
Signature o Applicant/Contractor ( Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT CM 100,000 BTU) ' Date' Recej Irl `
H7
defined by the Cupertino Municipal Code,Chapter 9.1 2,and the ` _
Healthed Safety Cade Section 25532(WP ° HEATING UNIT(OVER 100,00)BTU) TOTAL: l
M No
811he applicant orfuture building occupant use equipment or devices VEMIILATIONFAN(SINGLE REBID) ISSUANCE DATE -
S� which eMtbazarrent abrict? rants as defined by the Bay Area Air .. 'as`
�+ lity Management DlsMctt' BOILER-COMP pFIPOA 100,000 BTU) f�a�BpeX
I I Yes � n No "WI(�
ve read the lealtha Safety
materials rcqulrementsunder ChapterG95 of BOILER-COMP(OVER 100,000 BTU) C^
the California l&alth&Safety Code, 33 and 7x534.] - .oyt 12 1T]
understand that i(t bulldln ods not corn ave nan5thatitlemy NEW RESIDENTIAL METH. SQ.FI. 9Q.
rmponslbllllyt ' Ihlhe pantuftry�t creme which must 6e met ^
insviotse cecfa Ce ate ff h" cy. ("I
��� � � ._ '�.•fr(I�`j'j��_���pip
Owner or authorized agent _ Date _ ISBUfD BY,
TOTAL:
OFFICE.COPY