19771 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruett Identificatlah - - PERMIT NO.
Bulling Address:
,-v L 'a a cAevso
19771
ner• sine: 'I4a- 9'4(, APIUCA 110N SUBMITTAL DATE
F — CITY OF CUPERTTNO-BUILDING DIVISION ^ p f1
Lie.N°, APPLICATION I PERMIT V
AS �OAST(Z�.l CT11,1�, BUILDINGELWnUCAUMUMBING-MFGHANICAL CATEGORY CONTROL If
Architect/Engineer. Etc.Nce -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUAIJCE ❑ ❑ ❑
LICENSED CONTRACTOR'Sersed underDECns of Ch ON. - '
IhthSey on7OOm. Mtlaiv Mm3ofhe B,upruvblona P(ChapnsCodnmmen APPLIANCES-RESIDE JOB DESCRR'DON
lican.h Sectioli fewaskid a elon3oflhe BuainessandPro(eeeloneCode,and my
license Is in a force and effect. - PANELS
License Ctss Lie p
' Date - Contactor I/�L
ARCHITECTS DECLARATION 201-1000 AMPS
q�u aO ZOO I understand my plain shall be used as public records, OVER 1000 AMPS SQ.FT.FLOOR AREA $/S(1.FT.
!i (� Llcensed-Professiowl SIGNS ELECTRICAL
G�6 OWNER-BUILDER DECLARATION
yt, b Iherebya(Rrenthatlameurnpt fromthe Contractor'sLicenee lawforthe SPFCA CUIT/M
O .. foliawing reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.M - OR INST.. '
rr,4countywhlchrequtrsaper ttomnatrud,aller,lmpmve,dem"Iish,ormpalr go
anysmacture pdorte,Its issuance,also requouthe applicanthersuch permitto ppWERD
file a dgned rtatement th»MIs licensed pursuant[o the provtioru of the
3µQ Contractota Licerae Gw(CMpter 9(mmmeridng with Section 7000)of Diol- SWIMMIN L E
f.,� elon3 ofthe Bualneesand ProtembtuCodc)orthet he is exemp[[herefro..ad VALUATION
the bast far the alleged exemption. Any vlolatlon of SedWn 7031.5 by any OUTLETS H IS D D
p appeantfora permit aubjede the applicant toadvil pevlty o(not monationir
flue hundred dollars($500). NEW RIESIDENIIA LEC _SOFT.
❑I,ae owner of the property,or my employees with wages as tMLedoor STO TYPE CONSTRUCTION
��S°' mmperuatlon,willdothe work andtheetruduretnot Intended or ot(eretl for ,
D sale(Sec.7044,Business and Professbro Code:TM Contradote Licewe Law
does not apply to an owner o(property who builds orimpr°vea there
on,and -
hat such G.00GROl1P RFS.UNITS
who doceauchworkhimseBar Porwgh hisotvnemployeee,provided t
Improvement are not intended orot(ered(oreaor.If,however,thebulldingor TpTpL;
Imprevementtsold withinoneyearofcompletfen,the owner-bullderwlll have
t4QJZurdm of proving that he did not build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
L]L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 'i'
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contndor's License Law does not apply to an owner of property who ALTER
-DRAW BEs or Improves thereon,and who contracts for such p2ojeds -DRAIN&VENT-WATER ffFN with a FEE SUMMARY
6ctor(.)Bernard pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE
am exempt under Sec B-k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,fS1ND. SANITARY Y_ N—
saft WORKMAN COMPENSATION DECLARATION RECEIVEN
IF
FIXTURES PER TRAP SCHOOL 7AX Y N
❑f to o(ry affirm that i have• lmur t of consent d py themo ora RECEIPT If
rerti(Irate o(Workers'Comperisatlon7tuurance oracertl(led mpythereot(Sec. CAS F.A.SYSTEM-1 OUTLETS
3� gb C.) �OOp�31 pl PARKFEE RECEIPT
�omyny 7 "C d GAS EA.SY5TEMAVER6(FA) BUILDING DIVISION FEES
erti0ed mpyt he fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE �'—
❑ ertmad ropy i filed with IM city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhlesectlooneed notbecomplded ifth.permit leforonehundreddollars SEWER-SANITARY-STORMEA.200FT. Date Recei t#
(91I cedifeaa') In WATER HEATERW/VENT/eI.2cTR ENERGY FEE Y N
]certify that employ
any arson i any w worknner so as to b co eestnit is to ed,the —
I shaft not employ any person f any manner so as to become subject to the WATER SYSTEM/TREATING -
WorMrs'Compensation laws of Gll(ornt. Data pA]p
0 Z Applicant -
Z O N'OIICE TO APPLICANT:If,after making this Certificate of Exemption,you 'mow RESIDENTIAL PLMB. SQ.FT. Date Recei t# -
Fshouldbecomesubjeettothe Workers'Comperuatlon provisions ofthe Labor TOTAL:
W Code,you mu at forthwith comply with such provisions mthis permit shall be
BUILDING . 0
W > deemed revoked. b
aCONSTRUCTION LENDING AGENCY SEISMIC FEE t
IherebyafOrmtMt there t a construction fending agenry for the perform- '
M O ancoofthe workforwhichtht permltt Issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
-
V _ Lender's Name PLUMBING FEE
LL F Lender's Addreae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythat I have read thtappllestionand statethattheabovelnformation .
IL tcomed.Iagreetocomplywithalldtyand county ordinances and nate laws PERMITISSUANCE FEES PAID: . '
N relatingtobuildingcorutructlon,and Mrebyauthoriasrepressntatlemoftht - -
I.. Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. '
(We)agree to save,Indemnify an d keep harmless the City of Cu partino Date Receipt#
V
agalpst lis Illtlea,Iidgment,cone and expenses which may In any way accrue AIR HANDLING UNITIO 10,000 CFM) 'SUBTOTAL:
ag.i ata dCity In cwomque oft ng ofthis -
QMM AIR HANDLING UNIT(OVER I0,0D0CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCLOSURE
Willtheappllcant or future building occupant store or handle haeardoua HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Date Race] t#
HeWand Safety Code Section 2 32(a)7. HEATING UNIT(OVE2100,000 BTU) TOTAL: inau
Yea �No
Illlheappltcact or future building occupant use equipment or devices - VINRILATION FAN(SINGLE RESID) ISSUANCE DATE
I which emit havanlous air contminanta as deRned by the Bay Area Air r,
ality Mawgement isMct7 BOILER-COMP OHE',OR 100.000 BTU)
Yea No OR O I
ve read salt ar ous matedale tions 2ment 5533 and 2S5 4. I of BOR.LR-COMP(OVER 100,000 BTU) /"p
the California Health&building
Code,Sections25505,25533have
tc and 2S534. I rll
understand that if the building does not currently have.tenant that lttnry NEW RESIDENTIAL MECH. SQ.FT �ja grjO
W Ibility to notify the occupant of the requirements which at bsmn W
or laeuanreofaCa ate aocy. /)♦T
P �V
qlat
O rur or authorbed agent Darr- ISSUEDB
TOTAL: .
OFFICE COPY