20694 APPLICANT TO FILL IN INFORMATION WITHIN RELINES= USE BALL POINT PEN ONLY
D
'� Building Project Identification/,J�T)�A/ •Y 1 I PERMIT NO. /n�Q(Aj
Building Address. � •�U . '`{/YN a^'UVW I\33 y—, .Is Y O V'V T
Owner a Frosts:
CITY OF CUPERTINO BUILDING DIVISION. ' Q A
Cnntr ra me: `���/ APPLICATION I PERMIT S, ,
6V fia[ CAT[GORY" COMROL'M
•BUILDING-ELECTRICALPLUMBINGMECHAMCAL _ + .�
Architect/Engineer ♦ I- Llc.No: I '
QTY' ELECTRIC PERMIT• FEES BUILDING PERMIT INFO'
Adifirsise
- ' PERMIT ISSUANCE' 2-60
LICFNSFDCONTRACTOR'SDECLARATION - s
I hereby affirm that l am licensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL JOBDISC
ON
Ingwith Sedion7000)of Division3ofthe Busimssand Professlons Codgandmy + - -•
limnse is lnful a nddfect.., l' PANELS' (^�. ' N`�",.
Date Contneor -ALP",
(/', 201"1 WOAMPS
O Zp I understand my plasashall be used as public records. OVER1000AMPS SQ.FF.FLOOR AREA + $/SQ.FT.
if
'r4 ly Licensed professional SIGNS ELECTRICAL
1<•�j OWNER-BUILDER DECLARATION
n Fra - "ihl
I"' IhercbyafOrm am/hatlexemCom
moor's Coractorb ESPECIAL CIRC
License Law the -
Z O. q following reason.(Section 7011.5,Business and Professions Code:Any a ty or
an -
Emntywhichrequiiesapettommtmd,altepimpmveP
,de=lish,orrepair TEM 'MhTERO ST' ••
IL�g ystructure prierto its issuance,also requlrestheappllcaut forsuch permitto DEVICES
:5 (Ile a signed statement that he is licensed pursuant to the provisions of thePOVR -
O w Contractor's License law(Chapter.9(commencing with Section 7000)of Divl-
3p slon3oftheBuslnessandProf.ss .Cods,)orthatheisexerepttherefromand S NG POO E VALUATION
;! 4 the basis for the alleged exemption.,Any violation of Section 76115 by any OUTL SWI _ s -
applicant fora permit subjedstheapplicanttoa civil pemityofnut more thors t
pyo flue hundred dollars($500). 1NEW ALE TR SQ.FT, STORIES TYPE CONSTRUCT ION
(Gdl ❑I,as owner of the property,or my employees with wages as their sole
compensation,will dothe work,and thestructure b not intended or offered for
O sale(Sec.76t4,Business and Professlav Code:The Contractors License Law
c$$ does not apply to an owner of property who Wilds or Improves thereon,and _ZIA 11
OCC.GROUT' RES.UNITS'
who doessuch work himselforthrough his own employees,provided that such
Improvements are not Intended oroffcred for sale.If,howeveq thebullding or I TOTAL: `
improvementissold within oneyearofconipldiomtheowner-buBderwill have a
Men of proving that he did riot build or improve for purpose ofsale.). QTY, i PLUMBING PERMIT FEE.
t!t� PLODD ZONE APN
I,as owner of the property,am exclusively contracting with.licensed PERMrriss]ANCE'
contractors to mnrtmct the project(Sec.7044,Business and Professions Code:
The Contmetor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) "-
Wilds or Improves Ahamon, and,who contrecutfor such ptojecta with a -
0gIltjador(s)licensed pursuant to the Conlrador's License Law. FEE'$DMMARY
1_i I am exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR'ROOP,AREA,COND. SANITARY . Y . N •I
Owner Data RECE=#
WORKMAN COMPENSATION DECLARATION pD(TURES PER TRAIa - _ SpdOOL TAX Y N -
❑I hereby affirm that I have a certificate of consent to self-inwre,or RECEB'r X
cenJiwteofWorkers'Compeutlonl�ws mncemaccAIfkdcopythemof(Sec. GAS EA.SYSI'EM-1 INC.40U1L PARK FEE Y N
Policy# C.) - N FS 3 -G - RECEB'T# ..
Policy GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Com v Cr.^Ba•:.fl/ 'L
[�Certihed c y"ItTis,reby furnished. GREASE%INDUSTRL WAS- NTERCFPTOR PLANC14ECK FEE.
.. (TJCeetif ed copy I.filed with the city Inspection division ... . _ '..
CERTIFICATE OFIXEM"ION FROM WORKERS' CREASE TRAP : PAID.
COMPENSATION INSURANCE ^ - .
(Thissectien need not be completed if the permit b forces,hundred dollars SEWER-SANITARY ORM EA.2IXIF1'. } Date Recei t#
(8100)oify that
" WATERHEA %VENT/UFCTR - ENERGY FEE .Y N
I shall not employ any pence In any manner eo n to became subject to the WATER SY /TREATING "
Workcra'Compeneation Laws of Glifornla.Date - - PAID e'
C•'Z Applicant a . , NEW ENTIAL PLMB.. SQ.FT.r' Date Recei t#
Z O NOTICE TO APPLICANT:If,after nuking this Certlfkate of Exemption,you
Fshould become subject to the Workers'Compensation provisions ofthe Labor - TOTAL:
W Code,you must forthwith comply with such provlslmu or this permit shall be -BUILDING FEE
deemed revoked."
CL m 'CONSTRUCTION LENDING AGENCY I SEISMIC CL Ihercbyaff]reathattherelsacoratmctlon lendingagracy1munspamurn, ELECTRIC FEE
O
- 7 " once ofthe work for which this permit b Issued(Sec.3097,CIv.C.) TOTAL:
U O. 'tendmaNarrc PLUMBING FEE
_LL I- Lenders Address n - QTY. MECHANICAL PERMITI 'FEE° MECHANICAL FEE
O W Iceelfythatlhavemadthbapplimtbnandstatethattheaboveinforoatlon !y� 4
Iscorrcd.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE i W FEES PAID;
}'a relating to building construction,and herebyauthorlie representativesofthie
N citylo enterupon the above-mentioned property formspection purposes. ALTER OR ADDTO MECH.
Z (We)agree to save,Indemnify in d keep harmiessthe City of Cupertino Date -Recei t#
I) against llabl es,judgments,costatind expenses which may In any wayaccrue AIR HANDLING UMT(rOI0,000CFM) SUBTOTAL:
agalrat saltyle asequence of the granting of this,pe I A6 i AIR HANDLING UNIT(OVER 10,m0CFM) CONSTRUCTION TAX
UX
Sigwturc o(Applicent/Contractor' Data EXRAUST HOOD(W/DUCT) `- - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ' '
Wilithe applicant orfuture buildingoccupant store or handle hazardous HEATING UMT(TO103,000 BTU) - -OD .Date Recel f#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the s
Health and Safety Code Sedion2M32(a)7 HEATING UNIT(OVER ID),000 BTU) TOTAL: ' f-
'I ❑Yes Ir�-,1'No '
Will theapplicant orfuture building occupant use equipment or devices VENILATION FAN(SINGLE RESID) IS$ ATE
which emit hazardous air rontaminants es def]oed by the Bay Area Air
Q i.Iity Management District? I; BR'
OB.ER-COMP PIOR 100,00(1 BTU)
Yes Nohavconb
Ihave read the haza�oueaterials'requ]remenunde.rChaLER
pter 6.95 of BOI -COMp(OVFR IDope BTU)
the Callfarnla l lexlth&Safety Code,Sodium 25505,25513 and 25534.1
enders is ad that if the building dues not currently have a tenant,that Itis my NEW RESIDENTIAL MECH. SQ.Fr. /VIr /err �r
mspomibllity to notify the occupant of the requirements which must be meCk�t - w{s��syM ,
prior to Issuance of a Certificate of Occupancy. -
Ownerorauthoricadagem Date
TOTAL: �:;;bOLJ ISSUED BY:
OFFICE COPY