21468 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
yreB�u��ildln Pra en ldentl(katlen - PERMIT NO.
1044,0: S01 \Qr � 4- 21468
D' n, 1 N V a one:
CITY OF CUPERTIN0.BUILDING DIVISION ' 1 ` �0, R'n
m
f ttNa APPLICATION / PERMIT ` I�
Y-,0.LwA-44 BUMO1NG.ELECnUCA MWBINGMECHAMCAL CATEGORY C
a tett neer. `{��;V�1A BUILDING PERMIT INF
► �lJ Q ELECTRIC PERMIT FEE
( �ddrcsa PERMITISSUANCE ® ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrm that lam licensed under provisions of Chapter9(cummme APPEANCE5.RESIDENTIAL ]OB DESCRIPTION
ingwithSedi..700D).(DW,io,,3ofthpBusineuandPmieuloneCode,and my
limenee Is In fuB and.less. PANES
Llmnee lam Lk.N K`\tC.i`n
Date Contncto pr'IOWAMPS
ARCHITECTS gPCEVRAlhbN OVERIMAMPS SQ.FT.FL)DR MFA $/SQ.FT.
7. 1 understand my plan,ehaB be a bile records
qq�++ COC
k�tj Licensed Professional9CNSELECf1'RICAL I '
<;a .OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ 13�� -sv'sa
6hereb affirm thatlam exem fromthe Contndorb Llcenw Lawforthe b
Z Q� following reason.(Section 70(1.5,Business and Professions Code:My city or
OFP.METE2Oft EINST.
county whicstructure
pew
egWrnapeuNttomrutrouires the aprocantf r..ch permit
ir
to
$ any etmdurc pd to ersen, hat ho,Issuance,also sed pursuant t the rowistomof e pp EVICES
r'5 1 floe a setae.License
that ha t r 9(cod pursuant it the provision,of the
Owl Contnaoln Llcemelew(Chapter9(mmmendng wlthSection 7W0)ol Divi- IDOL
SOS Ile Basis for
the om alleged
Any)violation f Section
70315 by any S VALUATION
<, the Wan(or the alleged exemption. Any violation of Section not en by any I/C�/1//✓��
OA appBantlora permit subjects the applicant loo dull penalty of not morcthan O SITS s
five hundred dollars($W.
I,as owner of the roe myemployees8 NEW EL .Fr SNIIES TYPECONSfRUCTION
carnperxproperty,rta d wlthwa eau ffelrmo
-leo. 0K Ou.i heworkandthes Code:
eh net Intended or offered for
Oask(Seo 7041,0uslnevs and Profession,Code:The Contnctole Lim w
r'!a; does not apply to an owner of property who builds or Improves therm a d
3^ whodow suchwarkhimsellorthrough MsownemploycesprwidedthalOCC.GROIIIP RES.UNITS
improvements arena Intended oroffered foraale.If,however,thebuildin TOTAL:
ImprovemenHamld withinoneyearo(complabn,theowner-bu0derwlll ha
t rden of proving that he did not build or Improve for purpose of sale.). TY. PL ING PERMIT FEE FLOOD ZONE APN
UI,as owner of the property,am exclusively contracting with licensed P ISSUANCE
contactors to construct the project(Sec.7044,Business and Profession,Code:
The Contractor's License Law does not apply to an owner a property,who TTR-DRAIN&VENT-WATER MA)
builds or Improves thereon,and who contacts for such ;upje. with• FEE SUMMARY
.gwpdm(s)hmnsedpuauanttothe CordradalsUmnse Law. FLOW PROiFOT.DEVICE
UI am exempt under Sec B&P C for thin reason _
Owner Data RAINS FLOOR ROOF,AREA,COND. SANITARY RECEIVE N
WORKMANCOMPENSATIONDECIARATION SCI100L TAX Y N
emby affirm that I have•certificate of consent to self-Insure,a a FIXNRFS-PEA TRAP - RECEIPT'N
RFtlflate ofW.,kerV Campc h.Insurance or.certified copy thereof(Sex. GAS F.A.SYSTEM-1 RJG40UTLITTS PARK FEE Y N
3800,Lab Q
RECEIPT M
Policy NECE
' GAS EA.SYSTEM-OVER4(EA) - BUILDING DIVISION FEES
Com any
-ertlfied copy la hereby tumbhed. CREABE/WDUSIRL WASTEQRTRCEaTOR PLANCHECK FEE
Cbrtlfted copy 6 filedCERTIFCATE withthe
EMPy[ON FROM
er !��_� I `�
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP - PAID 110'-�t-
COMPENSATION INSURANCE SEINER-SAMCARLY-STORM EA 2IX)FI. Date ROcei t#
ffMsaectionneed
COMPENSATION
laForanehundred dollen
(8100)orless) WATER HEATER W/VENT/E.ECTR 'NERGYFEE Y_ N_
I artt/ythat la the performance of thework forwhlch this permit is issued,
I shall out employ any person in any money m u to become subject to the ylrATpt(SYSTEM/TREATING
Workers'Compensation Laws of GlBomla.Date PAID i��
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Reoei t#
`Z O NOTICE TO APPLICANT.If,ager making this Certificate of Exemption,you
fshould become subject to the Workers Comperaxtlon pron,visloof the Labor TOTAL:
N Code,you=at forthwith comply with such proWebn,orthla permit shall he 1
LLI `J deemed revoked'.
CONSTRUCTION b aON LENDING AGENCY SEISMIC FEE'
0 not the work
for w lherelaammtt Is End Lending agency for the perform- - ELECTRIC FEE
o Z lamderthe work(or which this permit Is Ended(Sec.3097,Civ.C.)
TOTAL:
U O Lender's Name � PLUMBING FEE
H Lender's Address QTY. MECHANICAL PERMIT FEE
O W ImnifythatlhavereadthbappBatbnand sate thattheabovelnlomutlon MECHANICA E!3 ` e
bcored.l agree to comply with all dty and county ordinances and date laws PERMIT ISSUANCE FEES PAID. I/0. 00 '
S7, DO
>: N relating tobuilding construction,and hereby authmUc repmd tativc•of this %I npu�L'Z�
dt mentiomd for W ion ALTER OR ADDTO MECH.
2 y to entero upon the abovcproperty wrpOBPDate Recei t#
(We)agree to save,indemnify and keep harmless the City of Cupertino P
V against said Cit a,pdgmequenestof the
expenm which may In anyway ecaue AIR HANDLING UNIT((010,000 CFM) SUBTOTAL:
against said City In mnsaryenm o!the granting of this permit.
AIR FTANDUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occtipancatom or ha od le hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety CI..25532(a)I HEATING UNIT(OVER 100,000 BIU TOTAL:
Yee No
WElthe eppliao r building ompant use equipment or devious VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air h__
a lity Management 'st ct7 BOILER-COMP pFm OR 100,IXD BTN C-Q'O
Y. No
have read salt o tecta ecttonlremenb5533 andChapter 2554.1 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code, on Curr ntly lb 2e.h and25534.it DECLY j1[Y
nopmoi ilitythat wllthtythe ongdoes nes emq.b haveatehi h thatitlamy NEW RISIDENTIAL MCC{i. SQ.IT. ,ryatY�
rnpon,ibilitym dl(y lheompant of the re nn wMch must be met
an Cert11Ic eo(Oavpaiuy. _ JINN IRF/1,_ C
r mraul riwda t �` Date TOTAL: ISSUEDBP„ � � 411.L�i-
OFFICE COPY