20681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prised Identification PERMITNO,
BnIldingAdds"os Be.ilo I . .1 20681
are. � !
CITY OF CUPERTINO0.BUILDING DIVISION
c°naan Name, m APPLICATION /PERMIT < '—
a, Cin-- BUfLDINGELECnUCALML BINGMECHAMCAL CATEGORY CONTROL#
FIT Arcfiltect/Fagl r. Lk.No:
r #L- BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
d .(/s t 6
Addreac9 3 PFRMITISSUANCE _lid ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions odChapW9(comment, APPLIANCESREADENTIAL ]OB DESCRIPTION
tngwith Section7DW)of DiAdon3o(theBu Fand PpofeuionsCode,andmy -
licensctsIn(uB ddfect. 6 6I y PANELS 'O .�• C
Date Clan - Lk.p /�G
Date c-om-or 301 IOOO AM I
ARCHITECT'S DECLARATION
Q�u nO Zp I understand my plane shall be used as public records OVER 1 AMPS SQ.FT.FLOOR AREA S/SQ. .
6i Licensed Professional SIGNSEL
< OWNER-BUILDER DECLARATION SPECIAL UI /
owing rsson.(ectTa 70315, tfromthed ProfctorsUonsa law(or the
o following which
eq(Section permit
to o Business and Professions Code:Any city or
F�1"'ty county which rcqulreeapermlt townstruct,0ler,lmprove,demoWh,arrepair TEMP. ft PcAiAr.
g 3 anystrucwre prior to Its Issuance,also requires the applicant for such permit to pOWF.R
f$ file a signed statement that he ts licensed pursuant to the provisions of the -
�a° G ContmcmesLicense law(Chapter9(mmmencingwith Section 700MofDivi- S'AgMM pCrR VALUATION
HRH sion3ofthe Busineuand Professlonscode)orthat he bexemptlherefromand
6 5 the bawls for the alleged exemption. My violation of Section 70715 by any E TC FI
applicant for a permit subject theappllcant to a civil penalty of not more than
five hundred dollars($500),
�r ❑I,as owner of the property,or my employees with wages as their ante R DENTIA FL SQ.FT. STORIES- 'TYPE CONSTRUCTION
mpersatlon,wllldo the work,and thestmcture once Intended or offered for
O uk&.7044,B..b ..rWPrf.l..Cade:The C..Od.e Ucenselaw
3$ does not apply town owner of property who builds orimprovesehereon,and OCC.GROUIa RFS I1MfS
whodoes such work hlmxlfor through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the Wilding m
TOTAL
Improvement osold within one yearotcomplefon,the owner-builder will have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING ERMIT FEE FLOODZANE AEN,
u L as owner of the property,am exclusively mntractlng with licensed PERMIT ISSUANCE
carnation to conslmct the project(Sec 7074 Business and Professions Code:
The Cmdad.e.License Law don not apply to an or of property who ALTER-DRAIN&VENT-WATER(EA)
Wilde or improves thereon, and who contfee such p7olem with. FEE SUMMARY
adm(e)licensed pursuant to the Contractor's License Law. BACK FIAWI'ROTECT.DEVICE
L j I am exempt under Sec B&P C for this reason
n DRAINS FLOOR RODE,AREA,GOND. SANITARY Y N_
Owner Drte RECEIPT N
WORKMAN COMPENSATION DECLARATION FMNRES PER TRAP SCI{ODI TA% Y_ N
�- ,❑I hereby affirm that I have a certificate of cmunt m self-Insure,or a RECEIPT N
certificate of mixos'Compeuatto"Iruuanceoracertifed copythemof(Sec.
.f' GAS EA.SYSTEM-1 INC4 OUTLETS - - PARK FEE RECEIPT•t.,, '380D,Lab CJ
Policy X GAS EA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES
Company
rtlfled copy is hereby l,rIh. ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14E•CK FEE
rtlfied ropy o filed with the city inspection divislan.
CERTIFICATE OF EAEM PTION FROM WOR KERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.l00PT. Date Revel [#
(Thisuctlonneed not ecompleted Blhepermit bfmonehundred dollars
0100)mless.7 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the pedman
orm of the work for which this permit is issued, —
I shall not employ any person in any nuumoi so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of CaB(omla.Data
PAID
O Z Applicant NEW RESIDENTIAL PWTB._SQ.FF. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation provblom of the Labor - TOTAL:
N Code,you at forthwith comply with such prmlaims or this perm0shail be BUILDING
LU C deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyefBrm
that there Is.construction lending agency for the perform- TOTAL: ELECTRIC FEE ,u
7 Z arceo(thewcokforwhichthis permit b Issued(Sec.3097,CIv.C.)
U O Leder.Name PLUMBING FEE
U. ~ Lender.Addmu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O .co
W Imre((ythatlhavercadehbeppBcatknaM stslethatthc above information
C rrect.I agree to complywilh all dty and county ordinances and orate laws PERMIT ISSUANCE FEES PAID:
>. N relating to Wilding construction,and hereby autharice representatives oftho
Z city to enter upon she abovo-mER entloned property for Inspection purposes, ALTOR ADD TO MECH, Dale Receipt#
(We)agree to save,indemnify an d keep harmless the City of Coped Inca
V against babNtles,ildgments,mks a nd expenses which may In any way acme AIR HANDUNG UNIT CFO 10,000 CFM) SUBTOTAL:
against said City in consequence of the grant Ing of this permit -
AIR HANDLING UNIT(OVER lo,r7flaCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is hazardous HEATING UNIT(TO I OO,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ,and the - —
-
IlealthandSafetyCade Section 25532(0? HEATING UNIT(OVER 100,000 BTU) - OTAL: - D
C-]Yesn No
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) I $ DATE
which emit harardous air cortandu nls as defined by the Bay Area Air
''L^ 'Illy Marugement District? BOTLFR-COMPOHPOR 100,000 BTU)
-71 Yes M No
vc read the fiaza casae materia.requirements under Chapter 6.95 of BOILER=COMP(OVER 100,OfA BTU)th,.&Iifornla Health&Safety Code,Sections 25505,25533 and 25534.1 01 CROP understandtat lfthe Wlldingdoes not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. Y2
maponsib' yt Ifyth occopa toftherequierment9whichmusiberret
1 u da Iticate of Occupancy.
net or authort d agent alt ISSUED BY:`
'TOTAL;
OFFICE COPY