20980 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPm ed dentlncation i,S /3 y foV V-0 PERMITN20980
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Building Add 2-.', ^33 6 l_ a/�YV N. �/ 2 0 g g 0
nen Name; one:
CITY OF CUPERTINOQBUILDING DIVISION
q-6-4?ma y� Nt1-1►1 Lie.N.: APPLICATION I PERMIT 0
CJ BLIILDINGELECTRICALPLUMBINC-MFGHAMCAL CATEGORY CONTROL N
ArchRect/Englrmer. LIB No: .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE Cas ElI5i'
LICENSED CONTRACTOR'S DECLARATION Jam[
I hereby affirm that lam licensed 3oftheunder provisions andloffusimsr odcom do APPHANCESRESIDENTIAL JOB DESCRIPTION
Incense I.in ollforceand Afelan3o(theguelmmand Pro(caelonv Code,endm �^� G+a •5.�,��
license Iv in fuB fors and Affect. PANELSLiconseClass
Date Contractor D/
ARCHITECT'S DECLARATION 201-IODOAMPS
ofOZ I understand my plana shallbeused as public records. a OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATIONSPECIALCIRCUIT/MLSC
zs, Iherebyafflrm that Iam exempt fmm the Contractor's License law for the
pp following reason.(Section 70)1S,Business and Professions Code:An city r
FZI"'8 cmntywhichrequimapenNttommtract,at,,impmve,demollah,ormpair 771HP.ME'fFR DRL'OLE INST.
a Aystm=m p riar to iw 6ma=e,a lso mqu im the a ppUcanl fm.uch permit to
file a signed statement that he la licensed j u e,ent to the provlslons of the POWER DEVICES
Owl Contractors Uceme,law(Chapter9(smmencingwilhSectlon7000)ofDivi-
30 s n3ofthe Bustnemand Profembm Code)orthathelaemm themfmmand SWBrfMINC POOL ELECTRIC - VALUATIONS
F by O the basis for the alleged exemption. Any violation of Section 70315 by any C&OUTLETS-SWITCHES-FIXTURES L 1Icz
applicant fora permit subjects the applicant to a civil penalty ofnn more than
pp flvn ndred dollars(55M.
I ace owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
c mpenas ion,wRl dothe workandthe structure la not Wended or offered for
0 le(Sec.7044,Business and Professions Cade:The Contractors Liceme Law
$ does not apply to an owner of property� whobullds or improves thereon,and^ who doessuch work himself wthrough his own employees,provided that such OCC.CROUP RES.UNITS
Improvements are not Intended oroftened for Bate.If,howeveq the Wilding or TOTAL: aC�
Improvement Is sold within one yearol completion,the owner-W IlderwiR have
t4g.jIunden of proving that he did cot build or Improve for purpose of sate.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed ppyp MANCE
contractors to constmd the pmjen(Sec.70114,Business and Prutessinru Code: T�a
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improves thereon, and who contracts for such p(o - -
jects with a x FEE SUMMARY
cgR¢ador(e)Rsnsed pursuant to Mn
e Conrado[.License Law, BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sea B&P C for this reason
- Owner Date
DRAINS FLOOR A,ROOF,AREGOND. SANITARY Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION HX7UNFS PER TRAP SCHOOL TAX Y N
t QP hereby affirm that I have a certificate of consent to Balf-Insure,ora RECEBT M
corti3800f1LdeorWorkere Compensatlanlmurance me certified copy thereof Caec. CAS HA.SYSPEM-1 INCA OUTLETS & PARK FEE Y N
Poll Y' GAS F.A.SYSTEM�OVER 4 TEA) DINGRRCEDIN
Y_
Com n4, BUILDING DIVISION FEES
MCertl(ied copy is herebyth the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�Certlfied ropy V(Ited with the dry Inspection divitlon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM FA ZOOFT. Dale RCCOI tN
(This section need not be completed If the permit fa for hundred dollare
(El00)wfWATER HEATER W/VENT/ELECTR ,-!_� ENERGY FEE Y N
I certify
that
Nmthat the perfornceaf the work(orwpermit
ch this peat is issued,
I shall not employ any person in any manner so m to become subject to the WATER SYSTEM/TREATING
Wwkeri Compe e.tion Lowsof California.Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB._SOFT. Date Recei t7!
Z O NOTICETO APPLICANT:IQsher making this Certificate of Exemption,you
1" Amid beronc subject to the Warknn'Compemation provisions ofthe Labor TOTAL:
N Code,you most forthwith comply withsuch provisions or this permit shall be U N
G FEE
W > deemed revoked.
LU C CONSTRUCTION LENDING AGENCY SEISMIC FEE
a. I herebyaffimn that them is a comtmcti.n lending agency for the perform- ELECTRIC FEE
M Z anmoftheworktorwhlchthbper 6L ed(Sa.3097,Civ.C.) TOTAL le
U O Lender's Name PLUMBING FEE
F lender's Add.. QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE Q7
O W comm.
Ignshavereply with alintlanandetatyordinances and gate
^
1
misting
ct.lagm to comply with andcityand Mmbcvuhorizenanmandstatslaws PERMIT ISSUANCE 14(� FEES PAID:
7. relat oenteru pont romuunloryloned peolmrtyor in representatives of this
Z
city(We)
ree toseeabovenoofyoned property for inspection purpose. ALTER OR ADDED MECH.
(We)agree m save,NdemN(y an d keep harmless the City o(Cupertino Date RCCeI (#
V against liabNt4re,jodgrnams,oarteand expenses which may m..ywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaWtsaiq_CAyyIco ence a fthegrantingo(thispemit.
O AIR I-IANIXING IMTT(OVER 1a,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contract., Da EXHAUSTHOOD(W/DUCII CONSTRUCTION TAX PAID:
IO
HAZARDOUSMATE LSDISCSURE
Will the applicant or future building pant atom or handle hazardous HEATING UNIT(70100,ODO BTU) Date RCCeI tff
material as defined by the Cupertino Municipal Code,Chapter 9.1 3,and the
Health and Safety Ion25532G)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes o
Willtheapplisnt future bullaingocevpant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
"which emit harardous air contaminants as defined by the Bay Area Air
silty Mawge.At Dotrin7 ROLLER-COMP DMPDR 100,000 BTU) PAAJ®
Yea
have read the hour us materials requlmnwnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Callfomla Health& (sty Code,Sectloru25505,25533and25534.I SEP 61990
undetslandlhatifthe ilding does not mrtenlly have a tenant that it is my NEW RESIDENTIAL MECH. SQ.FT.
mpomfb111tylondlfyth,o pantoftherequi..e tbwhichmustbemM ,
prlarto Lseuanceof Mcateo(Ocevpanty. (s;{4,- of Caperunoo�
nerorau o d gent r,�l--- �sJ,�l ISSUED BY: WlY\ 1rilT' �CJ./N..hI.Y'„rti
TOTAL: —4a�V
OFFICE COPY