20864 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
t, tluildln Project Identification PERMITNO.
8 Addms: • I s +q�- 20864
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/y1I v6' K O SS CITY OF CUPERTINO-BUILDING DIVISION —7.61
c, a
Contnnora Na
Lim.No: APPLICATION /PERMIT e 4
PiV C O BUILDINGELDC7RICAL-PLUMBRQGMECHAMCAL CATEGORY CONTROL N
1"AmIaltectlealpres�. Lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 90 JIM da12. '0A1. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ,
lherebyafflrmthat l am licensed under provisions of Chapter9(ourrommo APPLIANCES-RESIDENTIAL JOB DESCREPTION
Ingwlth&e ion7OW)of Division3ofthe Busionseand Professlon.code,and my
License Iain full force and effect. PANELS ax /B 1�
D
License Claw �r/F-1'L 1�sF
Date Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
p�p�uu aO Zp I understand my plans shall be used as public records. OVER I=AMPS SQ.FT.FLOORAREA S/SQ.
E� Licensed Pmfeestooal SIGNSELECTRICAL CO (��--C ��
GG 6 OWNER-BUILDER DECLARATION
In`ry SPECIAL CB(CIAT/M)SC
7 f'YI I hereby affirm that I n 7 31.5,B from the d Profess Contractor's License Law caths _
po following rtason.(Sectlan 70115,Buclnnsa and Pro(eesiOns Code:Any city or /
O Z l:. TEMP.METE20R PO INST.
I=E ounlywhichcture requlmapemdtro alsoreuireatheaprovGdemnWh,orir
to _
qill
any swcture tatemeits that he Isalsensed pursuant to the provisionorsuch s
ofpermit e POWER DEVICES
15 file a signed statement Law
het Banned pursuant to the proal 00) of Me
Contractor's License Law(Chapter9(commencing with Section7000) Divi- SWDAMINGPOOL E VALUATION -
O:J a n3oflhe$uslneasand Profemlora Cade)orthahebeaempt therefromand
the basis for the alleged exemption. Any Wolatl m of Section 70315 by any OUTLETSSW1W ES
O applicant fora permit sub)ens the applicant loa civil penalty of not morethan
$ Ove hundred dollars WM1. NEWRE9 AL EL
❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRIIC ION
7a compensation,will do the work and the structure is notlntended or offend for
❑ sale(See 70K Busmesa and PmAssiora Code:The Contractor.Llcen Law
$ does not apply to an owner of property who Wilda or Improves thereon,and OCC.CROIJIa ..RES.UNITS
who doessuch work himself orlhwgh htsown employees,provided that such )
Improvements are not Intended oroffered forsale.If,however,thebuildinga
improvement issoldwithinomyearofcompl&ioMtheowner-bullderwW love
tl}S,Ilumenofpmvmgthat he did not Wild or improve for purpose ofwb.). QTY. PLUMB GPERMIT FEE
L�[as owner of the property,am exclusively contracting with licensed FT-GOD TONE APN
ontracton to onatructthe project(Sea70b4,Businessand Professions Code. PERMITESUANs
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER ff-N
WIW.or improves thereon,and who contractscontractsfor such pk0jem - -with a FEE SUMMARY
cyV.ctar(e)licensed pursuant to the Cantnctora License law. BACK FLOW PROTECT.DENCE
LI I am exempt under Sec. B&P C for this reason
nllTqlnpvrrq
DRAINS FLOOK ROOF,AREA,COND. SANITARY Y_ N -
f Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑I hereby affl.that I have a certificate of consent to self-Inaure,or a FU('IVRES PER TRAP SCHOOL TAX Y N
? certificate of Warken'CompensationInsumnce ora certified copy themof(Sec. RECEIPT
3800,Iab C.) GAS EA.SYSTFM-i 1NG40lTILEIS PARK FEE Y_ N_
AECEITTN
PolicyN GAS EA.SYSTEM-0VER 6(FA) -
m any BUILDING DIVISION FEES
CKCArtffled copy is hereby te
Cert#led copy Is filed withh the city
inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEVER-SpMTARY-STORM EA.MOPE. Date Rewi t#
(TM&mdion need not be compiled If the permit ls for one hundred dollars
($10(fiarles`) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cenlfythat In the perfomanceof thework forwhlch this permit is Issued,
I shall not employ any person N any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compenxtion Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould bemmesubject to the Workers'Compensation provisions of the LaborI TAL:
t/1 Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
W j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
lhembyafl that then ls a omtruction lending agency for the perfomf TOTAL: 'ELEGTRIG FEE
D Z anceof the work(or which this permit ls Wued(Sec.3097,Civ.C.)
OO Lander.Name PLUMBING FE
LL I— Lender.Add resa QTY: MECHANICAL PERMIT FEE MECHANICALTEE
O W Icerti(ythatl MvertadthlsappBcalbnand patelhallheabuvem(ormatlon
fl isores
rct.Idgmeto comply with all city and county ordlnancand state laws PERMIT ISSUANCE FEFS PAID:
>. relating to Wilding construction,ction,and hereby authodrepresentatives of this
N
F F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date ReCel f#
I..I (We)agree to save,Indemnify and keep harecdess the City of Cupertino
Against liabilities,Odgmenls,cost...d expenses which may In any way Accrue AIR HANDLING UNIT(TO 10,=CFM) SUBTOTAL:
aga�los�tasa�id•City
`in onsequares of the fFaiding Of this permit AIR HA NDWNC UNIT(OVER 10,000CIM) CONSTRUCTION TAX
k�` V/7'Apo CONSTRUCTION TAX PAID:
Signature o(ApplHAZA HAZARDOUS
IXHAI)ST HCK)D(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant by the urc building occupant Cooreorhter, 9.haaardous HFA TING UNIT(10 100,000 BTU) Date Recci t#
material as Safety Code
Cupertino Municipal Codq Charter9.17,and the
Health and Safety coder�.S.section 75537G)7 lifiAT1NC UNIT(OVER]00,000 BTU) TOTAL:
❑Yes L_I Na
Will theApplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAN(FA40
which emit haeardous air contaminants as defined by the Bay Area Air
silty Management District? BOILER-COMP PHP OR 100,0(0 BTU)
n❑
Yea No AUG
'11990
have read the hanrdous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BT U)
t e Glifornia Health&Safety Code,Sections 75505,75533 and 75534.1
understand that If the Wilding does not currently have a tenant,that it I.my NEW RESIDENTIAL MFCA. SQFT.
responsibility to notify the occupant of the requirements which must be met , City of Cupertino
prior to lsemnm of a Cerdfiate of Ouapanry.
Owner or authorlred agent Dale ISSIJEDB :_
TOTAL: CV4 00
OFFICE COPY