20179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build In Pro eat ldentlrWHon P' TNO.
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Lk. CITY OF CUPERTINO-BUILDING DIVISION
c.n nnra//d�rame: ,A N.: APPLICATION 1 PERMIT `VV
�2xGI W 0✓L /'1 CG 3 Ll BUILDINGELECnUCALPLUMBINGMECHANICAL CATEGORY CONTROL Y
Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
fdd. PERMITISSUANCE ❑ ❑LICENSED CONTRACTOR'S DECLARATIONIherebyfbm that l am licensed under provWons ofChapter 9(whmen APPLIANCESRESIDEM7AL ]OB DESCRITION
...11.fullforceand died.3o([heBualnenandPro(essioneCode,and myesnae Is In onformendeffect. PANELS
Icenn Ckn ic.11
Cormando
rUP TO 2DO AhIES
ARCHITECI`S DECLARATION 201-IODO AMPS
he ZO I understand my pi..hall be need as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Iz� Licensed Professional SIGNSELECTRCAL
6 ttdu OWNER-BUILDER DECLARATION SPECIAL CUfT/
l herebyaffirmm
that l aexemptfromthe Contractor's License Law(cribs
following msson.(Section 7031.5,Business and Profession.Cade:An cityor
F� !qy county which requlremrm
sa permit tontct,alter,improve,demolish,orreair TEMP.M OR
IRS S enystm=mpHortolteB ance,alsorequimtheapphmntforeudipennitto WERD
s jQO
Bk b a signed statement that he licensed pursuant to the provisions of the
3 ec� Contractor's License law(Chapter 9(mmmencing with Section 7000)of Divi- NC LEL CI VALUATION
SOS alon3oftheBuainesfand P.9f.ioru Code)orthathehenmptlhemfmmand
the bash for the alleged exemption. Any violation of Section 7071.5 by any E7S TC p
applicant for a permit subjectstheapplicani to a civil penalty of net morethan - 1 V
five hundred delta.ISM. WR L L SQFC. STORIES TYPE CONSTRICTION
F11,as owner of the property,or my employees with wages as their wk
C c mpeneation,wOl do the work,and the structure h rwt intended or offered for
$ O alk Sec.70K Business and Pm(enloru Code:The Contract.?.Llrerue law
( $$ does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RES UNITS
whodoneuchworkhimaelforth.ghhisownemployeea,pmvided thatsuch
improvements arc not intended or offered for sale.If,however,the building or TOTAL
improvement iswld within..yearofcompletion,the cwner-bu llderwlll have
t rden of pmvlog that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Ll,as owner of the property,am exclusively contracting with licensed PEAR ISSUANCE
contractors to construct the projed(See 7046,Business and Professional Code:
The Contractor'.License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER IPA)
builds,or Improve thereon,and who contracts for such p(ojetts with a - FEE SUMMARY
�gBt(�ctor(a)Bnnaed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under See B&P C for this reason
OUTSIDPars
DRAINS.FLOOR, A,COND.ROOF,ARESANITARY Y N
Owner Date ftFCh]I'PN
WORKMAN COMPENSATION DECLARATION FIXTURESPERTRAP SCHOOL TAX Y_ N
❑1 hereby affirm that 1 have o Imunne of amn if d apythsure,ora RECEIPT Y
ce00,Leeof Workere'Compematlon liuunna ora certifkd mpythereo(f5ec. GAS.EA,SYSIEN-1 INCA OUTLETS PARK FTE Y N
3800,Lab C3
PNky Y NG DI N
GAS-PA.S
EYSTEM-0VER 6(EA)
Com any BUILDING DIVISION FEES
ffCertlBed copy is hereby famished. GREASE/INDUSLRL WASTE INTERCEPTOR PLANCHECK FEE
certBied copy b filed with the city Inspection division.
Y„ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1'. Date RCCeI of
This motion need nn be completed if the permit h forum hundred dollar
($100)or len.) WATER HEATER W/VEM/m rr.T.R ENERGY FEE Y N
I certify that In the performance of the wok(orwMch this pemdt is issued,
I shall not employ any person in any runner so as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws.(California. Date PAID
-
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.PT. ' Date Recel t#
0 NOTICE TO APPLICANT:If,after making this CeElficate of Exemption,you
should become subject to the Workers'Comperuatlon pnevislmu of the Labor TOTAL:
W Code,you muatforthwith comply with such provisions or this permit shall be
LU deemed voked. 1 •E
W � recaCONSTRUCTION LENDING AGENCY SEISMICCFF EE '
Q. G l hereby affirmthat there is a mrutmction lending agency for the perform ELECTRIC FEE
Z sees of the work!or which this permit is Issued(5re.3097,CIv.Q TOTAL:
U O lander.Name PLUMBING FEE
LLF= lander,Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O L) ladifythailhavereadthbappllutlonaMgatethattheab.veinformation '�QS FEES PAID:
a ismrrect.I agree to complywith all cityand county.rdleancesand state laws PERMIT ISSUANCE
} W relating to building construction,and hereby authorize representativn of this
F" Z city to enter upon the abowmentioned property for Inspection purposes. 1 ALTERORADDTOMIECH. Zs� Date ReCei [M
V — (We)agree to love,indemnify an d keep harmless the City of Cupertino �ee�y� P
against liabilities,judgments,mets and expenses which may In anywayacerue 3 AIR HANDLING UNIT(TO 10,ODO CFM) 1 W SUBTOTAL:
against said City In consequence of the granting of this permit CONSTRUCTION TAX
AIR HANDUNG UNH(OVER 10,ODOCFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE a�
Wllltheappflcant orfuture,building oaupant atom or handle hazardous HEATINGUMTOO 100,00011M Date ReceI tN .y J4dn
material as de0md by the Cupertino Municipal Cade,Chapter 9.1 7,and the
Health and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU/ TOTAL:4b"t I
❑Yee r!No
Will thrfuture building oavpant use equipment or devices VENTILATION FAN REBID) ISSUANCE DATE
e applicant o
which emit hazardous air contaminants as dented by the Bay Area Air
Qu Bt Management District? BOILER-COMP l3HPOR 100,000 BTU)
4Yee N.
ha'smad the hace[P smaterials requirements underChapter6.95of BORER-COMP(OVER II3,I)D BTU)
the Gllf smla Health&Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does not comedy have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
ropoMlbilllytonctllythe panto(therequlrementewhichmuetbecom
prior Lssuarmofa Ce f to of OwopanryIV. N��Y
J
Ow ormth zed. rat Date ISSUED BY:y — �,
TOTAL:
OFFICE COPY