19935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildln Pmf,rt Identification I PERMIT NO.
Building Address: 1 9 9 3 5
42 �o buS �UE•
aces: QCAP$q 2
CITY OF CUPERTIN0.BU[LDING DIVISION
C15rra' JAPPLICATION I PERMIT
�
L BUILDING-ELECnUCALPLUMBINC-MEC LAICAL CATEGORY CONTROL M
Architect/Engineer. Lt.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERhRTI55UANIX ❑ ❑ ❑
LICENBED CONTRACTOR'S DECLARATION
Thereby hSectio lrmthat lal lgmsedheBusiunder rovandP fCMon,Codemmrnc APPLIANCESRESDENTIAL JOB DESCRIFT10N
Ingwith Setlion7000)ot DlWston3ofthe BuslneuandlProfeW9naCade,and my r7_r_� ,r•1
license le In(u a and dfmt. PANELS
License Claes Lk.tl
Date RT24'- Cantnctor a'�+1�a•
ARCHITECTS DECLARATION W[L'�� 2014"AMPS
rx�O IuMentand my plane slug be used upublic remrde.' flw.b OVERIOOO AMI'g SQ.Ff.FLOOR AREA f/SQ.RI'.
�Zrv7 Licensed Professional SIGNSEDCAL
OWNER-BUILDER DECLARATION SPECIAL pp T/MLSC
I hembyaffirenthat l amexerept fromthe Contactor'sUmme Law for the
following reason.(Setlion 7Q91 S,Business and Professions Code:Antl or
FSI" countywhlch mqulresa permit tomntnct,alter,Improve, m
deoltsh,oreepalr TEMP. IN
any stmtlure prkr to its Iowans,also requires the applicant for uch permit to
� I file a signed statement that he B limned pursuant to the provisions of the ppWFRD
w� Conladoe.Lice.IA.(Chapter 9(commencing with Section 7000)of Divi. rN L E C
SOS slon3 of the Business and Profession Cods)arlhat he B exempt therefrom and �WIMVALUATION
Qthe basis for the alleged exemption. Any violation of Section 70312 by any E
applicant for a permit,ubjecis the applicant to civil penity of not room than
five hundred dollars(SM. EL TR SQ.FT. STORIES TYPE CONSTRUCTION❑I,as owner of the property,or my employees with wages as their sole
7s, coropcosatlon,wlildothework,andthe structure B not Intended or offered for
q sale Igoe.7094,Business and Profession Code:The Contnctofe License law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who doessuch work himself orthrough his own employees,provided that such
Impmvemenu are not Intended oroffered fm ule.If,however,thebullding or TOTAL:
Improvement Is sold within oncyeamfmmpletlon,the owner-W Ilderwlll have
(IiLlIurden of proving that he did not Wild or Improve for purpose of sakJ. QTy, PLUM GP RMIT FEE FLOOD7DNE APN
L as owner of the property,am exclusively contracting with horn d PERMIT ISSUANCE e'1
contractors to construes the project(Sec.7094,Budness and Profession Code:
The Contractor's License Law does not apply to an owner of property who AT k -WATER(EA)
Wthereon,and or Improves,thereand who contracts fee such p(ojecnx with a FEE SUMMARY
�q➢t�ador(s)Ilmnsed pursuant to the Contractor's Ltmnse Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under Sec B h P C for this reason
' OUTSIDEFEES
Owner DaleDRAINS FLOOR ROOF,AREA,GOND. SANITARYRECEIPT Y
WORKMAN COMPENSATION DECLARATION el
I hereby affirm that I have a cartifi atr of consent to self-Insure,m a FIXTURF3'PER TRAP •� SCHOOLTAX RECEIPT NY
(lateofWorkers'ComFer timIl mmmaartlfkdmpythereof(Sec. GAS EA.SYSTEM-I INC.40I11LET5 PARK FPR Y N
Poli Lab C.) s O 1 l S^3 _ RECEIPT M
Pollrytl W L GAS EA.SYSTEM-OVER4(EA)
Canv BUILDING DIVISION FEES
omfCertifled ropy is hereby fumlehed. GREABE/WDDSIRL WASTE INTERCEPTOR PLANCHECK FEE
$zCertlRed copy B filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2D/F1. Date Recti t#
(Thorsess.) need not edcamplMed If the permit B(m on hundred dollars
(f]IO)nWATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify
tthhat In the pedornunao(Ihe week(orwMch this portrait Is Bwed,
I shall not employ say person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Gll(amB.Date PAID
O Z APpllant- NEW RESIDENTIAL PLMB. SQF7. Date RL i t#
Z O N'OUCETO APPLICANT-,H,aRer making this Certificate of Exemption,
you
W should beer.subject to the Warken'Compensation provisions of the L.Wr TOTAL:
Code,you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING FEEW
UQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affim"hat there B a oontwdlon Lending agency for the perform TOTAL: ELECTRIC FEE
D Z anceof the work for which this permit Bissued(See3071,Civ.CJ Or
00 Lender'.Name PLUMBING FEE
LL F Lender,Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W IarUfythatl have read thisapplkatlonard Matethattheabove,information FEES PAID:
1 Boomed,l agento comply with all cityand ecuntyoedlnances and Yate laws PERMIT ISSUANCE
T W relating lobulldleg constwctim,and herebyaulhorue,representatives ofthis
Z city to enter upon the abovcmentbnd property for inspection purposes. ALTERORADDTOMECH. Dale ReceiPl#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,judgments,ooYaand expenses which may In any way accrue AIR HANDLING UNIT G010,ODO CFM) SUBTOTAL:
wnid City In of th rating of this permit.
/ �y°�P�'!��/'-,e�` j�" ��2��q0 AIRIiANDWNG UNIT IO,OW CFM' CONSTRUCTION TAX
Slg amt .fAppBant/C.1mc1uur -- bl Dat EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hamodous HEATING UNIT(TO IOD,ODO BTU) Date RmeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cedction 25532(a)7 HEATING UNIT(OVER 100,00D BTU) TOTAL: 72A f2-
nYes No
Willlhe appliant Ature building occupant use equipment or device VENT!LATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit hares rdous air contaminants as defined by the Bay Area Air
Quality MangemenlD trict7 BOILER-CAMP pFO'DR IW,IXD BTU) PAW
4Ya o
h.ve read the h az cus materials requiternents under Chapter 6.95 of BOMER-COMP(OVD9100,000 BTU))
the Calfamia Health A Sa(My Cod,Section 25505,25S33and 25539.I ��
understand that if the building does not currently have a tenant,that it B my NEW RESIDENTIAL MECH. SQ.Ff dl 44 w
responsibility to nes lty the mmpa rat of the requirements which most be met
pce aCerll ate of parry.
MF 812,4190 aQ(Dodo
o authr agent II1 'Date ISSUED BY:�J,E�.7��M—'•a"
TOTAL:
OFFICE COPY