20166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.---: USE BALL POINT PEN ONLY
Building Proert tdemlf c,lun - PFRMIT NO.
Building Address: CR) c}<F_T H ILL,) 20166
wAPPU�HUN SUBMI 1-1 AL
0-0pTH VDL-AAS, one. CITY OF CUPERTINOQBUILDING DIVISION
C tractT�or. a
ama:6kjiYs++ Lie.No: APPLICATION /PERMIT D / U
O/7 N 5- BUILDING-ELF TRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL N
Arched/Enginesr/^: Lic,No.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby efif that lam Licensed under provisions of Chapter 9(mmmenc APPLIANCESRESIDENTfAL IFJOB OFSCRTPTTON
Ingwlth SedW.7000)of DiW.lon3ofthe Bueinnsand Profession Code,and m
liamn Is In fu
Llcenes Class efecPANELS
Lk,Y Col` Y NF% Rre �i x
Date cmuredor
ARCHITECPS DECLARATION 201-IMOAMPS
pQ+p GO I understand my plata shall be used n public records. OVER 1000 AMPS, SQ.FI.FLOOR AREA $/SQ.FT.
E o U Licensed Professional SIGNS ELECTRICAL
«<< Lu OWNER-BUILDER DECLARATION $pECULCIIiCUIT/
MI
7F Ibereby a(Rrmthatlam exemptfmmthe Contndori Llcerue LAwforthe
pp following reason.(Section 7071.5,Business and Professions Code:Any city or
K71" county which mquiresa permit mcorutmct,alter,Improve,demoish,mrepair TEMP.METER LE
any.tructum prior to its issuance,a iso requires the applicant for such permit to O POWER pgW file a signed statement that he is licensed pursuant to the provisions of the
wt; Can/.doe.Llcnese IA.(Chapter9(mmmencingwlth Section 7000)of DWI- SWIMMING POOL C _
SOS emn3 ofthe BusinessndPro(essbmCode)orthat hebexempVALUATION
tthere(rom.rd 6O
O the bash for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects theappllcant to a civil penalty of fid more than OUTLETSSWITCES ��S
fi5uu dreddollars(5 M. NE pS(p EC SQ.FI. STORIES TYPE CON5TRIX:770M
I,as owner of the property,or my employees with wages as their Bole
c mpenaation,wdl dothe work,andthe dmctam is et Wended or offered for
p sale(Sec 7064,Business and Professions Code:The Contactoe.Lt..law
$ don not apply to an owner of property who Wilds or improves thereon,and 7 A OCCGROIIP RES.UUNITSwhodonnchworkhm fforthrough Msownemployoos,providedthatarch . ,
improvements are not Intended motioned for sale.It however,the ding
or T
improvement b Bold within one yearofcompldbn,the owner-bullderwlll have
tl%lZurden of proving that he did not build or improve for purpose of sale.). QTY. P BINC MIT
u L as owner of the property,am exchulvety contracting with licensed FT-OOD TONE APN
contractors to mn.tract the pro)ed(Sec.7064,Business and Professions Code: PERMIT ISSUA
The Contractor's License law does notapply to an owner of property who �Tgg-DRAIN&
Wild. or Improves thereon,and who contracts for such ptojeda with a FEE SUMMARY
�7�(+dor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
1_J I am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEBTM
WORKMAN COMPENSATION DECLARATION FDITURF_SS Plat TRAP SCHOOLTAX Y N
01 hereby affirm that I have ocertificateInsurance
c of consent to opythereo or RULE T Y
Mae,ab of Workers'Compemation lrauranm ora certl(kd copythereef(Sec. GAS EA.SY9TEM-11NC4 OUILEM PARK FEE Y N
3800,Lab G RECRTr a
Conry Y GAS EA.SYSTEM-OVER 4(EA)
,o�m+any - - BUILDING DI VISION FEES
u Certified copy is filed famished,
CertifiedGREASRANDUSTRI,WASTE INTERCEPTOR PLANCHECK FEE
copy is hereby fa the city Wpectlon division.
CERTIFICATE OF ID(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT Date RCcel IM
(Thlasedtoo need nor be completed if the permit is forces hundred dollars
(5100)mless.) WATER HEATER w/VEM/ELECTR ENERGYFEE Y N
I certify that in the performance of the work for which this permit is issued,
I stall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workere'Compareation Laws of California.Date PAID
O Z Applicant NEW RE9DP.NITAL PLMB. JQ.FT. Date Remi Ile
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemptloq you
Fshould become subject to the Workers'Compensation provbm bof the Labor TOTAL:
N_ Code,you at forthwith comply with such pruvlslamorthi.permit shall beLW > doomed revoked.
BUILDING FEE IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE L
IhembyafRrm that there is a construction lending agency for the performTOTAL: ELECTRIC FEE
M Z ance of W
he work which this permit is Issued(Sm 3097,Civ.C.)
U O Lender.Name PLUMBING FEE
LL 1— Lendrea Address QTY. MECHANICAL PERMIT FEE
O W Imrti(ythat l have read thisappBatlonand datethattheaboveinformation 'MECHANICAL FEE
6 sommt.l agreetocomplywith allcityand coantymdinanonand statelaws PFRMTIISSUANCE FEE$PAID:
} relating to Wilding corutructi a,. dhereby.whorize representatWnof this
F. N city to enterupon the above-mentioned property for inspection purpose. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei tg
V agaimt liabilities,judgments,"sand expenses which nay in anyway accrue AIR HANDLING UNIT CO IO,ODO CFM) SUBTOTAL:
agal ai tyi onequenceof the granting of this permit. n
5-1U-90 AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
_
Will theappliant or futurebuildingouupant storeorhandle hazardous HEATINGUMT(T0100,000 BTU) Date Recei tN
material as defined bythe Cupertino Municipal Code,Chapter 9.1$and the
Ifealthand SafetyCode n25532GI? HEATING UNIT(OVER 300,000 BTU) TOTAL: \
n
Yes No
Til the applicant
or(uture Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) 1$SUA ATE
which emit bxza Mous air contaminants as defined by the Bay Area Air
Quality MawgementD t BOILER-COMP(3HP OR 100,000 BTU) - a��
Yes
Ihave mad the hazy ou.omaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) I
MAY
'l ✓ 9c )GJ ,
the California Health&Safety Code,Sections 25505,75533 and 75534.I M
understs nd that if the building don not currently have a tenant that it is my NEW RESI DENIIAL MECH. SQ.FT, - —
responsibilitytonotifytheoccupantoftherequirermeis which=at be mart ^IL ^II'
Prior to hauanre o! rtlfkateof Occupancy. City 4 pprtino
� t DataTOTAL:
ner or aulhodzed agent •Dace ISSUED BY:
TOTAL:
OFFICE COPY