20130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
lldbuildingPru cert Idendfkaion is.4 rn(/m �� PE 1 20130
8uing Addras:
�Z ,0 l V* 3 /
r. ante: ane: `I
d/ 2 Si ITY OF CUPERTINO-BUILDING DIVISION 7� , q'."50 PM
ontnct«'s Nme
a : LIc.N. APPLICATION / PERMIT
Ar.-hken/Fs nee o: BIALDING¢ECIWCAJ PL INGMECHANICAL CATEGORY CONTROL
aq 0. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ada gY&0 1A !$SlejA) Jo PERMITISSUANCE 1:1 ❑ ElLICENSED CONTRACTOR'S DECLARATION
I herebyffbm that l am lke,oed under provWan.of Chapter 9(cmnmm APPLIANCES-RESIDENTIAL JOB N
Ingwlth Section 7000)of Division 3 ofthe Budeess and Profeasims Code,and
IYerue b In full Forex and effect. PANELS / 1 �N �•
Lum.Clams LIn Y (
Dae Contractor
ARCHITECTS DECURATION 1-1000AMI'S
W�z I undenetand my plane shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
y Lfanaed Professional SIGNS ELECTRICAL ����
�< OWNER-BUILDER DECLARATION SPECIAL ClftCUIT/ s
zE- z Iherebffl
yarrnthatlareemnapl fromilm Contnuetors Litms elawf«the
following nam.(Sectlen 7miS,Ruslnessand Profesbtu Code:Ary cityor
F t-� mu 0ntywhkh rrqubnapemJt tommauct,
alter,Improve,demohah,ormpair TEMP.METER OAI'O ST.
�4
Y,,� anyamcumpMtolbbsoancgaborequ4 theappllantf«sochpermitm
C file a signed statement that he h licensed purprovisionsunt to the provisions of the POWER DEV Ar
VICES
Oa Contractors Lk<me Law(Chapter9(mm
meneug with Section 7000)of Doi. SWIhfhB ¢NCPOOL
, �O1 Yon3ofthe Buslneeand PrMerbm Code)or that hula caomptthenfromand VALUATION
ln3il •.t the hash for the alleged e.emptlon. My halation of Sectlon 70315 by any y�
�L 'E ISSlV17LfiES
appE.ntf.r.pemdt.bjemthnappUc.tt..dhlperuhy4.a.o thin
n. fiundred dollan(5500).
�n �I,as owner of the property,or my employee with wages as theirsole NEW R® SQ STORIES TYPECONSIRUCTION
eumpemadoe,wW clothework,and the struefore b wt Intended or offered for
110 sale(Sec.7014,Bmlnee and Prefmioru Code:The Cmdractora Lim.Law
g does not apply to an owner of property who builds or improves thereon,and
mss^ whodoessurh work hlmxlfoethrough hbawnempbyees,provided that eh OCCGROUP RFS UNITS
Improvements are wt Intended oroffered for sale.If,however,the Wlldlog or TOTAL;
Improvement baold within oneyearofcompletion,the ownerhllderwW have
ft,tyrden of proving that he did not wild or Improve for purpose of axle.). QTY,I PLUMBING PERMIT FEE
1,u owner of the property,am ehrsWely contracting with Itemsed FLOOD ZONE APN
rc
contractees to mmtruet the pm)ect(Sec 7014,Bminesa rdrof
Peuiom Code: FFAkffTI55UANCE
The Contractor's License,Law does not apply to an owner of property who ALTER-DRAM&VINE-WATER ffN
Wilda or Improve thereon,and who mancts far soch p�ojecta with a
19114sehor(a)lloeru%d pursuant to the Contractors License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B&P C for thus reasonOLFTSIDEFEES
Owner Data DRAINS FLOOR RODE,ARE3,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RBCEBT Y
1]I hereby affirm that 1 have a cenBkate of consent to self-Inoue,or a FI ILTRFS PER TRAP SCHOOL TAX Y_ N_
m (la
rtlte of Worken'CommsoPince«
peaoa ia eertifled copy thnmf(lkc. RECEIPT
3800,Lab C.) CAS FA.SYSTEM-1 NC-4 OUTLETS PAFRKFFR Y_ N_
RFCFWT A
Pdry A GAS U.SYSTEM-OVER 4(FA)
Com ray BUILDING DIVISION FEES
f�certWed ropy us filedherefuminhed. GREASE/MDUSIRL WASTE INTERCEPTOR PLANCHFCKFEE
CenRied ropy b(iled'Mth the dtY Impectbn division. �
CERTIFICATE OF UETFPTION FROM WORKERS GREASETRAP PAID /" b 13•53
COMPENSATION INSURANCE SEIVER- STORM-STORM FA 3'%8,-I. Date Recel Ip
(lids seNan need not be completed if the permit b f««e hundred do)[.
(310 cer l®3 WATER HEATER W/VENYIEFEctR ENERGY FEE Y N 10
Iaettless.) nthe perfomunce ofthew«kforwhiNthispemdl lslwed, 1V• QD
1 shall net employ any perm in any manner w ate to become subject to the
W«kere Compensation laws of California.Dan WATER SYSIFA7/TREATING PAID
ZZ Appllant NFWRF9DFNF[ALPLMB. SQFT. D Remi tit '
O NOTICE TO APPLICANT:lf,after maWng this Certificate of Faemptbn,you
should become subject to the Worken'Compemat ion pravhlom of the Laver TOTAL:
~ N Code,you must fon hwhh comply with such prnvuslom or this permit"I]be
W ] deemed rewked. -
coNguoN LENDING AGENCY
BUILDING FEE _�z
a ] ISMIC FEE /
Ihenbyafflrm that there ba ronstruction kmdingagency forthe perform, TOTAL ELECTRIC FEE
n
Z am of the workfor which this permh b hsed(Sec 3041,CW.C.)
00 Leader.Name PLUMBING FEE
1- Iendre.Add. QTY. MECHANICAL PERMIT FEE
O W Icenifythalhewe dtMappB tionandsatethathe.bovclnfoLL rmetim MECHANICAL FEE
bmrmct.I.gmetocomplywkhaUdtyandmuntyordkunmandmtelaws PERMIT ISSUANCE FEES PAID:
>. N Mating to Wilding mrmtauction,and hereby.uthorlu representatives of this
Z city to enter u Pon the above-membrcd property for bupectbn purposes. ALTER OR ADD TO MECH.
(We)agree to uve,Indemnify an d keep harmless the Clry of Cu pen]m Date Receipt#
V agaWt llabill aexpenseswhlchmayinanywayamue ADR HANDLING UNIT CTO 10,0)0 CPW SUBTOTAL
ago eque o he granting of this permit
AIR HANDLING UNIT(OVER IB,"CEM) CONSTRUCTION TAX
I
CONSTRUCTION TAX PAID:
Sigau p / retract« pate kYI IAUST HOODIW/DUC'p
HAZARDOUS MATERIALS DISCLOSURE
C�Wlllthe applicant«Future wilding oavpant atom or hvdle haurdau HEATING UNIT(TO 100,000 BTU) Dale RttCI 1#
materbl as do0aed by the Cupertino Mu Nr3pal Code,Chapter 9.17,and the
Health and Safety Code Section 75537(a)T HEATING UNIT(OVFR 100,"BTC) TOTAL: cu
�Yes W s
the ipphaeu«L�i�utune Wilding ompsm uu equipment or device VFNIILATIONFAN(SMGLRRESD) ( ATE
whkh emit banrdnus air meta Mounts as defined by the Bay Area Air JULqnn
Quality Management DbtdnHIO T BORER-COMP OOR 100,0(D RTI))
Yes L 03 IJJ0
❑No
t. I have raid thehvaNmu nuledals mquimmenb under Chapter&95 of ROILGR-CVNP(OVER I W DW BTU)
the CalBorma Heahh&Safety Code,Sections 75505,25533 and 75534. I /��_�
understand that if the wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. _ SQpT a..ryof eff
mapomBWhyt iy the P the mquiromonts which awn be net ��v sa//�t WW1IB�'�� tI�
prior to fka s Pa racyorzv .
uth« ant Dae
TOTAL:
OFFICE COPY
I