19791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY
Building
ldin Project Identification PELWTN
Build ing Add reN_ 19791
• Phone: p
nsr CITY OF CUPERTINO-BUILDING DIVISION -",.>—"C)^tra '•Name: APPLICATION / PERMIT '
. YOG BUTLDINO-ELECTRICA MUMBING-MFGHANICAL CATEGORY CONTROL Is
ArchimettEngines, Lk.No:
QTY ELECTRIC PERMIT FEE , B�UILDING PERMIT INFO
Address: PERhRTISSUANCE Ik/� .❑ [:1 ❑'
LICENSED CONTRACTOR'S DECLARATION I v
Ihereby ion7Dthat fDivi censeauaderpmmand olChapterg mionsCode,ammo APPLIANCES JOB DFSCRB•'UON
ing�fice..h in
apOp)ot Dlvlelon3.fibs BualnessandProleesloneCode,end rtry 1 (
license is In full(o and effect. PANELS
Date
Chea LIeN_ 0 r '��
Date Contractor 20110DOAMPS
ARCHITECTS DECLARATI�
a O I understand my pkns shall be used n public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/9Q-FT
E� Licensed Professional SIGNSELECTRICAL _
<6 - OWNER-BUILDER DECLARATION
�2 SPECIAL CIRCUIT/MISC
ZF I hereby affirenthat l am exempt from the Contractors License law for the
following reason.(Section 70715,Business and Professions Code:Any city or
Fe'u9 countywhich mqumu.permit mnscetmtt,alter,Improve,demolish,orrepalr 'LEMP.ME[EROR MST.
q MSg� anystmmmpaortob.rewame,alsorequireslheappRcantfmsuchpert tto
I`red Bk a signed statement that he Is IlrenaM pursuant to the provisions of the POWER DEVICES
3w� Contractors License Lew(Chapmr9(ra.mingwith&ttbn9W0)of Dlvl- SWIMMING POCKELE
I- O elon 3.fthe Business and Profeaslone Code)or Mat he is exempitherefromand VALUATION
O the basis for the alleged exemption. Any violation of Stolon 7031.5 by any O ETSSWITC
applicant fora permitsub)rrathe applicant to a civil penalty of not more than ( tD
R five hundred dollars($500).
NF%*DENTLkLjKTR Fj
I,as owner of the property,or my employees with wage a their wk STORIES TYPE CONSTRUCTION
ompenutim,wW dothe work andthe structure is am Intended or offered for
Osa1e(Sec.7044,Business and Professions Code:The Contrad.e.License law
5$ does not apply to an owner of property who Wild,or improve,thereon,and OCC.GROIIP RFS.UNITS
who don suchwmix himxUorthrwgh Ms own employers,provided that such
Improvements are not Intended omffered fee sale.l4 however,lhebuilding or TOTAL: "
improvement resold within one yea rotcomplellor,the mm er-buBderwlll have
theburden of proving that he did not baud or Improve for purpose of sale.). QTY, p . BING PERMIT FEE
Lf FLOOD ZONE APN
b as owner of the property,am exclusively Business
ess contracting with 1lcensed P UANCE
conThe C.rhatocostruct License Law
(Sect appy Businessand aprol.ns Code:
The Coor improves;
License law aces who apply to an owner of property who ALTER-DRp1N&VENT-WATER(EA)
bullas or Improves thereoa,and who contracts for such prajem with a FEE SUMMARY
licensed See to the Gomractors License Law. BACK FLAW PROTECT.DEVICE
LL��I am exempt under&c. B&P C for this rcnon
OF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner ECL .RELEBrIN
WORKMAN COMPENSATION DECLARATION
T10N FDaURES.PER TRAP SCHOOLTAX Y N
Or hereby affirm that I have a beams a of concent to opythwrc,ora RECEIPT N
3800LaortfifieteofWorke�CompensaRon;rouran�r�rtifled ropythereo((Sec. GAS EA.SYSTEM-1 WCAOUTLEI'B _ PARK FEE RECEIPT '
3800,Lb CJ AA C. / 2
I'o11ry Y GAS EA.SYSTEM-OVER 4(EA)
Com any `� BUILDING DIVISION FEES
L-j0 Certifies py,is heed with
the city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�certmea ropy re mea with the ay inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA 'PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.pDFl• Dale Recei t#
(Thissection need not becompleted Blhe permit lefm ons hundred dollars
(§100)n•la
I cem fythat in the performance o(thew.rk(orwMch this permit is assured, WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workera'Compensation Laws of California,Date PAID
Z Appficant NEW RESIDENTIALFLMB. SQFT. Date Receipt
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become xiI to the Workers'Compensation provisions of the Labor TOTAL:
(A Code,you at fon hwith comply with such provisions or this permit shall be
j deemed revoked. BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE a
Iherebyamrmthat there re a construction lending agency for the perform TOTAL. ELECTRIC FEE
n Z ance ofthe workfor which this permit is heated(Sec.3097,Civ.C.)
00 Leaders Name PLUMBING FEE
LL F Lamers Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedityov
lhatl have readthisapplicalion and statethattheabe lnformstion
1 is ordinances ct.I agree to comply with all city and county ordinansand gate laws PERMTTISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives ofthis
cit to entero n the above,mentlonext propertyfor On ion ALTERORADDTOMECH.
~ ? y(We)agree save,indemnify an d eeharmless s tM1 Clry ofT.7tiw Date Receipt#
V as tllabilitica"dgmnnts,coasand expenses which may in anywayamue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
t.ald City n consequence of the granting of this permit AIR HANDLING UNIT(OVER I0000 CIM) CONSTRUCTIONTAX '
a aAt ,y ��^� h'� 7-s_C— CONSTRUCTION TAX PAID:
Slg ture of AppppXecant/Contractor ,a5 " Date EXHAUSTHOOD(W/DRX:T)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 101,000 BTU) Date Receipt
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Heath and Safety Code Section 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Will the applies^tor tum building occupant use equi pment or devices VENTILATION FAN(SINGLE RESID) ISSUANaOE'DATE
which emit bars rdous air contaminants as deo red by the Bay Area Air �^ •
liality Management Di Mctt BOILER-COMP PIT OR 100,DM BTU)
rT,Yes No
have madthe Nazar us materials rcqulrements under Chapter&95 of BOILER-COMP(OVER 100,000 BTU) rilkZ ab j�c
the Callfomia Health& ety Code,Sections 25505,25573 and 2534.1
understand that lithe buildingdoes not cvrrenllyhave a tenant,that It is my NEW RESIDENTIAL MEIN. SQFT.
responsibility,to notify the occupant of the requirements which moat be mad '�ll�'I of(•IIen�InO
pn.r to issuance do Certificate.f 0.Peary. ''j�}�4�
Owner or authorisedTOTAL:agent Date ISSUEDBY: bF—
OFFICE COPY