20387 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification _ PERMIT NO.
Building Address: /�0^n
aa ;A r C'y� r%vo .C�.�a( G VK{8
ne . ante:
�L Sf(off CITY OF CUPERTINO6BUILDING DIVISION
omntlora Name: Mc.N. APPLICATION /PERMIT 7 l
�I /- BUILDING-IIBCTWCALPLUMBINGMECHANICAL CATEGORY CONTROL e
Arch)ed/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address ELELI
PERMITISSUANCE �(•� ❑ K
` (�j ❑
LICENSED CONTRACTOR'S DECLARATION �(
I hereby afIrm that am licensed under provisions of Chapter9(comment, APPLIANCES-RESIDENTIAL JOB DPSCR�7��1''11ON
Int.scismfullfirma DlWtlon3oflheBudnmandPro(mloneCude,and my PANELS YSi w(r- �y(,e
license b in full farm and effect. �.J ✓✓UU'9fl I�`^
License Cissa ontr UP TO 2DOAMPS em -_ Fj „1_,
Date Contractor 301 ODOAMPS (4' WGJ , a+.aaCJ
ARCHITECT'S DECLARATION
MOO I understand my pisco shall be used as purecords.c records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FI.
lei �j Llmnsed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECLILCEKUIT/
Zt, a I hereby affirmthat l am exempt fromthe Contractors License law forthe
following reason.(Section 7¢315,euslnm and Professions Code:Any dty or
O ticmntyw7QdP.M OR LE
Pla anystmhimphoritai p amt alorequimthimprove,dem cher ttr
any structure tatements issuance,alcensed re man,, he novisi permit a POWERD
file a signed statement that he b licensed pursuant to the proWioru of the
3w Contractors License Law(Chapter9(mnurcncing"It Section 7000)of Divi. SWATMING ElUvOWA I t I VALUATION
SOS abn3.fthe BuelnmandPa.l.r Cod.).,Ih.t hebeaempttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
a0 applicant for a permit subjects the applicant to a civil penalty of notmere than OUTI'47S IIW�
rue ndred dollar(5500).
'9..' I,as ower of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
O AAs
satlon,willdothe workaod theetructure b not Intended.,offered for
le(Sec 7011,Buslna..and Professions Code:The Contractors Liecrue Law
$ does not apply to an owner of property,who builds or Improves thereon,and
who doessuchworkhtmself orthrough hleownemployees,provided that such rem OCC.GROUP RFS UNITS
Improvements are not intended oroffered for sale.ILhoweverCZ
,thebulldingor TOTAL: 19
improvement issold within oneyearofcompIMkrytheowner-bu8derwill have
t1)£.Ilu,den of proving that he dM not build or improve for purpose of safe). QTY. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
PERMIT ISSUANCE
contractors to mrulmd the project(Sec.7614,Buslnm and Professions Cade: \eY
The Contractor's License Law don not apply to an owner of property who ALM-DRAIN&VEM-WATER(EN1 y
builds or Improves thereon, and who conct
tras for such p(ojeds with a FEE SUMMARY
��Rtl+cror(a)homard pursuant to the Contractors License Law. BACK FIDWPROTECT.DEVICE 1WLJ I am exempt under Sec B&P C for this reason OUTSIDE FE17S
M OE DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Own Date RECEIPT M
RKMAN COMPEN TF N DECLARATION ,
❑I ereby e(flrm that I have•certl0cata of consent to self-imm�,ora RO(T11RES PER TRAP Stli00l TAX Y N
RECEIPT M
certificam.f Workers'Compemation Uauareems ttrtifkd mpythersef Sec. GAS. SYSTEM-1 OUTLETS PARK FEE Y N
3800,LabCJ SRECEIPT M
Polity p GAS EA.SYS[EM-OVER 4(EA)
Cam any BUILDING DIVISION FEES
Certlfied copy It hercbytd. CREABE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CcrtNed copy b filed withh the the cid,
inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREJISETAAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei [#
(rmssedkn need rad be compleed If the permit b forom hundmd dollen
(f100).rkss.) WATER HFATERw/vENT/FJ.ECTR ENERGY FEE Y_ N_
I cortify that In the performance of the work forwhich this permit Is band,
1 shat not employ any person in any manner so as to become subject to the WATFlt SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
C' Z Applicant NEW RES DENTIAL PLMB. OFT. Dare Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Worken'Compensation provisions of the Labor TOTAL:
!A
Code,you comply with such provisions orthb permit shall be BUILDING
W j deemedrevoked.
CL O CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform- �y ELECTRIC FEE
7 Z an tt o(theworkforwMchth pNr tbbvred(Seo.M97,Civ.C.) TOTAL:
V O Lende,.Name PLUMBING FEE
LL F Lender.Address - QTY. MECHANICAL PERMIT IEE MECHANICAL FEE
O W I mrtifythat l have read this appllcathmand a tate thattheabove information
1 iscorrect.I agree to comply with all tlty and county ordinance and gate[am PERMITISSUANCE FEES PAID:
relating to building construction,and hereby auth.rlu representatives of this
N
F. Z city to enter upon the above,mentloned property for Inspection purposes. ALTERORAODTOMECH. Date ReCCIFnI#
(We)agree to save,Indemnify an d keep harmlm the City of Cu ped Inca
V against Babilltickjudgments,costa and expenses which may In any way accrue AIR HANDLING UNIT(f010,f100 CFM) SUBTOTAL:
against said City in cone uence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,0)0 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date E7(HAUST1100D(W/DUICp CONSTRUCTIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) -Date -ReCel [#
- material as defirred by the Cupertino Municipal Code,Chapter9.12 and the
Flealth and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: PO
RYn MN.
111 the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit harard.us air coma mlrants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR 100,000 BTU) ,
4Yea ❑❑No
haa•ereadthehazarc .morrialsrequlrementsunder Cha pter6,95of BOILER-COMP(OVER 100,000 BTU)
the Glbfomla Health&Safety Code,Scdioru 75505,25533 and 25534. 1
undentandthat if the building don not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of t fmquiremems which moat be and
a ttof Certlncato sept
rauthorimd ag
At Date TOTAL: ISSUED BY:
OFFICE COPY