19679 APPLICANT TO FILL IN INFORMATION WITHIN•RED LINES — USE BALL POINT PEN ONLY
Buildin Project Ideadflcatlon - PERMITNO.
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M6 V LT�Z'q CITY OF CUPERTIN -DUILDING DIVISION
C tra es amr: ����s.s LI=.N ' APPLICATION / PERMIT
�'"�'/R2, BIIILDINGELECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �Sl
Ihereby affirm that l am licensed under provisions of Chaptxr9(commene, APPLIANCESRESIDENTIAL JOB DESCRIPTION
IngwlthSe on7000)of DiAAm3ofthe Buaineasand Pmfe onsCode,and my
liceUP TO 200 AMI?9
nsolsln andafest D PANELS ,
Limn C L1c.N
Da Contractor- 201-IODOAMPS I
ARCHITECTS DECLARATION
P❑±
9
0 O I understand my plate shall be used as public records. OVER 1 ODO AMPS SQ.FT.FLOOR AR S/SQ.FT.
E b�j Licensed Professional SIGNSELECTRIC
OWNER-BUILDER DECLARATION
SPFL7pLCRtCU[T
2s, F, Iherebyaffirm that lam exempt frmnthe Contractor's License Lew for the
qo lollowing reason.(Seco..7031.5,Business and Pmfe®ion.Code:Any city or
Fps" countywhich requbeaa pemdttomtetrua,alter,Improve,demolbh,rumpalr TEMP.METER RPO IN
anystmmmpr wie Wuawgal mquimtheappbantfwwu pert tto POWER DEVI
Ole a signed statement that he Is licensed pursuant to the provisions of the
�O w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- PliMMING P;OL
Oe Won 3 ofthe Business and Profemlons Code)milut he iaezempttherefromand VALUATION
the basis for the alleged exemption. My violation of Section 7031.5 by any Q E.ISSWI.I.0
appBant fare permit subje b adsre
the applicant to a civil penalty of nmathan
.five hundred delta.($500). NEW D A
❑I,as owner of the property,or my employees with wages as their sole SQFL STOWFS GDNSIRUClIDN
compensation,will do the work and the structure is not Intended or offered for
0 saIsCSee 7014,Business and Pmf.kma Cade:The Commodes Licenelaw
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUIs RES.UNITS
E
who dceasuch work himself orthrough his own employces,provided that
each _
improvements are not Intended oroffered foraxle.If,however,thebullding or TOTAL:
Improvement4wMwithinmeyearofcomplet mtheowner--d-ndnhave
14LJ;urden of proving that he did not build or improve for purpose of sale.). QTY. BUNG PERMIT FEE
u FLOOD TONE MN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
Thecontractors to construct the wprofectdoe(Seo 7D44,apply
Business and Professions Code:
The Goor I.P.e Ll th a Law does tis apply ro an owner d property who ALTER-DRAIN/s VENT-WATER(EA)
cbuildsonte t r Impthereon,and who contacts !or such p(ojMa with a FEE SUMMARY
�'gp(factor(sexemut d pe under Seced.
Me Contractor's Llanx Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reawn
OUTSIDE FEES
DRAINS FLOOR ROUP,AREA,COND. SANITARY Y N
Owner Data RECEIPTM
WORKMAN COMPENSATION DECLARATION FIX,NRES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o certltra c of consent to op thereof
ora RECE1PT N
38M ate of Worken'Compensatlan Insurance ora certl(kd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
poll Ieb C,) ,_/ _ q &7 7- RECEIPT N
Pollry n�(=�3["�H 4 GAS FA.SYSTEM-OVPR4(EA)
Com v p[i0�� - BUILDING DIVISION FEES
ECertifiedcolahereby famished. CREASE/INDUSIAL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Lt filed with the city inspection division.
CERTIFICATE OF UKMPT ION FROM WORKERS' GREA'SE7RAP PAID
COMPENSATION INSURANCE
( SEWFR-SANITARY-STORM EA.200RT. Date RCCeI t#
1d.sectfonneed not becompleted ifthepermit laforonehundred dollars
(51centlytha
I t WATER HEATER W/VENT/ELWTR ENERGYFEE Y 'N
fiores.) tithe performance ofthe wmklorwNch1Ms permit is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SYS.IEMMEATING
Workrs'Comparealion Lawsof California.Data PAID
—
z
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Work<rs'Compensation provisions of the Labor 'TOTAL:
— Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE t
tl I hereby efgrm Cher there la a construction lending agency for the performs ELECTRIC FEE
Z a scarf the ivmkfor which this permit lalsxued(see3097,CIv.C.) TOTAL:
U O I<.dce.Name PLUMBING FEE
LL F Iaadre.Address QTY. MECHANICAL PERMIT FEE
Ow Imdt.Iagretoco plywitppllatyand cdatethrtenances and
ldan MECHANICAL FEE
ll relating
ecoingt Iagm to coeplywlth altd hereby
auhormrnancesand gate PERMIT ISSUANCE FEES PAID'.
N citat oenterulldingconsove construction, ooxdprop authorize mpresenpurpos of this '
cit(We)
ru the,Indemnify ad a feeInspectionion pea. ALTER OR ADD TO MECH.
H Z y pO" property rty pe=I Pt`pO Date Receipt#
(We)agree to save,cod,codsan d keep es whharmlich
the ina of Cupertino
V
against liabilities,jidgmenls,emt.and expenses which may in anywayacwe '. AIR HAND[1NC UNH(TO 10,000 CFM) SUBTOTAL:
agalnstaid Cityin consequence of a ant ofthb stout.
AIR HANDLING UNIT(OVER 10,000C[M) CONSTRUCTION TAX
sig reo Applicum/Contrade Date EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOU ATERIALS DISCLOSURE
Wlllthe eppifant orfamre eliding occupant store or handlehuardoue HEATING UNIT ]OO,ODO BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Sect) 25532(a)2 HEATING UNIT(OVER 100,000 BTIN TOTAL:
❑ Ya [t7 -1a
Will the applicant or town,building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which sent hazardous air contaminants as defined by the Bay Area Air
Quality Management 'triol BOILER-COMP DEO'OR 100,000 BTU) PAID
4Yea o
havercadthehua o rials requirements under Chapter 6.95 of BOILER-COMP(OVEE100,000BTU) MAR 081990
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand/haofthebuUdingdcesnotcurmntlyhaveatenanLthatitismy NEW RESIDENTIAL MEIN. SQ.IT.
responslbOitytonollty I eccoa nto(thercqulre nt..hkh must be
pci nmof a Certlfkat c an Ci 0,f rup".ro
Owner awhodu TOTAL:
agent Out ISSUED BY:4 K V LJ(.L
OFFICE COPY