20138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification PLRMIT NO.
Building Address: //
Oen r �9vY Cu r�Tiu 20138
ams: ? one: A A A
CITY OF CUPERTINO-BUILDING DIVISION Li� 1 -7,1C
con�.ytor's Name: �a. f ue.No: APPLICATION I PERMIT L v
BUILDING-ELECTRICALPLUMBING-MEC}I LAICAL CATEGORY CONTROL x
Architect/Engineer. Lic.No:
'1 QTY ELECTRICPERMIT FEE �a�,BUILDING PERMIT INFO
Address: E L ',•' ,V DAA+ W eA PERh4TISSUANCE o? I` ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc APFLIANCES-RESIDEMIAL JOB DESCRIPTION
Section7(XU)of Divisloo3 ofthe Businessand ProfessionsCodc,and my
license is In full force slot effect. PANELS ^
License clam e'/0 Cont <IrO</o O % 2 , 1] A��,`
Dae Contractor ✓
ARCHITECTS DECLARATION 201-1000 AMPS
oto O Z I understand my plans shall be used as public records. OVER 1030 AMPS - SQ.FT.FLOOR AREA S/SQ.FT.
I"i Licensed Professional SIGNS ELECTRICAL
��c.w OWNER-BUILDER DECLARATION
pL�jj IherebyafOrmthatlamexempt fromthe Contractor'sLicenselawforthe SPECIALCItCUIT/MISC
z0 following reason.(Stolon 7031.5,Business and Professions Code:Any city or
rr,7fe't9+ county which mquires,a permit to construtl,a)ter,Improve,dernall, orrepalr P.METEIi OR POLE INST.
q'm�SCI any structure prior to Its Issuance,also requires the applicant for such permit to
6 rc L�7 file a signed statement that he Is licensed pursuant to the provbloruof the POOR DEVICES
Contador's License Law(Chapter 9(commentlng with Section 7000)of Dlvl. SWIMMING POOL ELECTRIC
f-bb sion3 ofthe Business and Professloru Code)orthat helsexempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70312 by any
w Psu
OUTLETSSWITCFESEXTURESappb ntforaetbKtheaPP1icanttoadvllpees1 oRom,bn
flue hundred dollars
($500). NEWRESIDENHALELECTR
I,as net of the �� STORIES - TYPECONSTRUCTION
�n ❑ property, employees with r offemd for
their
C compensation,Business andwiltdothewkandlons Cdumbna IntendedorLaw
'S O salesnot.does not pply 70K Business Property Code:The or Improves
License law
whodoso;sUchtornownelofproughhisonemporimprovnthemoRand OCC.GROUP RES,UNITS
who doeasuch work himsel(orthrwgh his own employees,provided that such
Improvements are not Intended oroffered for sale.I(however,lhebuildingor TOTAL: 6 y,
improvement b sold within oneyearofcompletion,the owner-bullderwlll have
tfjf,�urden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIAODzONE nPN
L j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the Project(Sec.7044,Business and Professions Code: ..
The Contnctor'e License Law does not apply to an owner of property who ALTER-DRAIN&VENT.WATER(FA)
Wilds or improvn thereon, and who contracts for such ppajects with a
q¢t�actor(e)Iicensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
c LJI am exempt under Sec. B&P C for this reason
Owner Date LS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N OU � .
RECEIPT0
WORK MAN COMPENSATION DECLARATION FD(TURFS I'ER.TRAP SCHOOLTAX Y_ N—
hemby affirm that I have a certificate of consent to self-insure,thereof
ora RECEIPT x
2,61L GAS-
oracertl(led ropylhemof(Sec. GAS-EA SYSTEM-1 INC4 OUTLET
W,lab C0 PARK FEE Y N
Policy x RECEIT p
Cam any GAS EA.SYSTEM-OVER4(EA)
❑certified copy E hereby fuminhea. BUILDING DI VISION FEES
❑Certified copy filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXOVlPHON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Hossection need not becompleted ifthepermit lsloronehundred dollars SEWER-SANTTARY-STOEM EA,200FT, Date Recei t#
(St 00)orf that
WATER HEATER W/VENT/E.ECM ENERGY FEE Y N
(certify that In the perforrtanceo(the work(orwhich this penNtishsued, —
I shall not employ any person in any manner su as to heroes,subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Calllomla.Date PAID
Ct Z Applicant
Z O NOTICETO APPLICANT,If,after making this Certificate of Exempt ion,you NEW RESIDENTIAL PLMB. nQ}7, Date Recei t#
should become subject to the Worke s''Compensation provissum coition Labor TOTAL:
WN Code,you most forthwith comply with such provislons crthls pernJtshallbe
> deemed revoked. BUILDING FEE
a o CONSTRUCTION LENDING AGENCY !SE FEE
I hereby affirm that there E a construction lending agency for the perform- IC FEE
7 Z dace of the work for which this permit is issued(Sec,3097,Civ.C.) TOTAL:
U O Lemief BNimP NG FEt'L F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL
O W I cortifythat l have read thLsappliatlanandatatethatthcabova Information
1 L+rormct.l.greeto comply wlm all city and county ordinances and state lawn PERMIT ISSUANCE D:rrelatingtobuliding constmctlon,and hereby authorise representatives ofthis� cttytoenterupon the abovcmenBoned Property for Wpectlon purposes. ALTER ORADDTOMECH.
(oe)agree to save,indemnify an d keep harMss the Clty o!Cupertlno against liabilities,Judgments,costsand expenses which may in anywayaraue AIR HANDLING UNIT(To ig000 CFM)
against said City In consequenm of the granting of this permit. AIR HANDLING UNIT(OVER 10,(X10 CFM) UCTIOIXI-IAUSTHOOD(W/DIKT) UCTIO :HAZA R DOLS MATERIALS DISCLOSUREWill theappllant orfuture building occupant store or handle hassrous HEATING UNIT(TO tO,000 BTU)material as defined bythe CupertinoMunidpal Code,Chapter9.i2,and the _
}Iealth and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL•
❑Ye No
Will the applicant or(uturc building occupant use equipment or devices VWRLATION FAN(SINGLE RESID) ISSUANCE DATE
Which emit havrdos ai
ur romaminants u
as defined by the Bay Arca A
Quality Management District? BOILER-COMP O}E'OR 10000 OTU)
4Yes ❑No s
havercadthe h Nmateriabrcquirementsundc,Ch.ptc,6.95of BOILER-COMP(OVER 100,000 BTU)
the Gliforola Health&Safety Code,Sedions25505,25533 and 25534.1 -
understandthattfthe building son not currently have a tenant,that it b my h'EW RESIDENTIAL MECH. SQ.FT. SSVYSS'=V+✓✓✓
responsibility,to notify the occupant of the requirements hich must be met
prior to Issu of a Ifica O
or au or gent Date ����..yy��a ��������
TOTAL: ISSUED BY: /�.�{.�.{
OFFICE COPY