19685 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN.ONLY
Building Project Identlfleatimi - PERMIT NO.
ennahZdrc,,: - - ; - - 19685
ner� 2�V Versa; CITY OF CUPERTINO-BUILDING DIVISION Z
Con arson's Na - Lie.N. APPLICATION /PERMIT
BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Englmer. Lie.N.
QTY ELECTRIC PERMIT, FEE BUILDING PERMIT INFO _
Addreae: - PERMITISSUANCE t ❑ ❑ ❑
- LICENSED CONTRACTOR'SDCCLARATION
Iherebyaffirmthailamlkns uMerprovblonsof Chapter9(mmmmc APPLIANCESRESTDENIAL -)OB DESCRIPTION
Ingwlth Se ion7000)of Divislon3ofthe Businenand Professions Code,and my
license is In ffp
_e effect
/ PANELS
License Cbn �`Lk.N
Dat ContractCC or UP
ARCHITECTS DECLARATION 201'1000 AMPS m" —
µppµ!!rezI understand my place shall be used n public records. OVERIOOOAMPS SQ.FT.FLOOR f/SQ.FT.
E Iz�j U Used Profenbrul SIGNS ELECTRICAL It
<�t OWNER-BUILDER DECLARATION SPECIALCItCUfT/MISC
Z f, a Iherebya(Irmthatlam exemptfromthe Contractor',License lawfm the
following reason.(Section 7mlS,Business and Profession Code:An tl r
K, countywhich requires percoutumcetruct,alter,improve,demolish,orrepalr TEMP.METER OR N -
MaeystructompriortoIts iswance,also requlrestheapplicant for such permit to POWER EVICES'
V file a signed statement that he Is licensed pursuant to the provisions of the
O u,t9 Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
30 slon3 ofthe Business and Prefemloce Code)orthat he in exempt therefromand SW1MMI POOL EL VALUATION
/�the bast.for the alleged exemption. Any violation of Section 7031.5 by any ' ` ��
p applicantfora permit subjects the applicant to a civil penalty of net more than OUTLETS %7118 /
Rghundrcddollars(f500). NEW REST LBCTR SQ,FI. STORIES •CONSTRUCTION
�n a I,as owner of the property,or my employers with wage as their sole
mmpcnsatlon,will do the work and the structure Isnot intended or offered for
sale(Sec.70K Busbies.and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improve thereon.and -
EE whodoe.suchworkhim tforthr ghhlsownemployen,pm idedlhat.ch OCC.GROUP RFS.UNITS
improvements are not Intended or offered for sale.It hemmer,the building or TOTAL:
improvement Is sold within aceyearofcomplallon,the owner-builder will have -
thLtumlenefproving that he did not build orimprove for purpose cfsate.). QTY, PLUMBING PERMIT FEE 20(-20020 ZONE ApN
u L as owner of the property,am exclusively corseting with Bmnxed PERMIT ISSUANCE
centrsctors to construct the proeo project(S 7044,Business and Profeniuce Cade: •
The Contractor',License Law does not apply to an owner of properly who ALTER-DRAIN&VENT-WATER RN
WIW$or Improvn thereon,and who contracts for such projects with a FEE SUMMARY
151actor(s)licensed pursuant to the Contractor's License Law. OACK FLOW PROTECT.DEVICE
am exempt under Sec. B&P C for this reason
Q'�TclFuR.:17u
DRAINS.FLOOR ROOF,AREA,COND. SAMTARY ' Y_ N
. Owner Date - .. .
RECEIPT M
WORKMAN COMPENSATION DECWRATION FO(TURESPER TRAP SC11OOL TAX Y_ N_
C31I hereby affirm that I have a mMBcate of consent to .self-Insure,ora 'RECEIPT N
certificate of WorkersCompersation Insurance era certified copy thereeMee. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Tab Ca) RECEIPT N
Polity it RECEIPT[fGAS E.A.SYSTEIN-0VER 4(EA)
Com
any (f�•//}t. BUILDING DI VISION FEES Certfifed py Is herebytum
Certified copy with the city city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑ .
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID .
COMPENSATION INSURANCE $EWER.SANITARV-STORM EA 2(XffC Date RCCCI t#
(This section need net be completed if the permit Is for
one
hundred dollars
(f100)orlev.) WATER HEATER W/VENC/Q.ECI'R' ENERGY FEE Y N
I cartlfy that In the performance of the work for which this permit is Issued, .:
I shall not employ any person in any manner an as to become subject to the WATFIt SYSTEM/TREA77NG
Workers'Compensatlon Laws of California. Date PAID
'C! Z. Applicant - NEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z O NOTICE TO esub)a APPLICANT: after making this Ctionpreis Exemption,you
Hshould become subject to the Workers'Compensation provisions of the Lobar _ TOTAL:
CC W Code,you most forthwith comply with such provisions orth s permit shall be BUILDING FEE .5 7
W 9 deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there Is a mrabuction lendingagenry for the perform ELECTRIC FEE
Z anmofthewerkforwhlchthbpermltbi ed(See3097,Civ.C.) TOTAL:
02 Landers N.me PLUMBING FEE '
LL U L.Ia?.Aylheti have readihIsappBcatbnand tlalethattheabovelnformation QTY MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iscorrect.I agme to comply withal]city and county ordinanmsand Nate laws PERMIT ISSUANCE FEES PAID: -
U) relating tob.iWing mcehucion,.M hereby authorize representatives ofthis
Z N city to enter upon the above-mentlonM property for impecdon purpose.. ALTERORADDTOMECH. '
? (We)agree to save,Indemnify an d keep harrileas the City of Cupertino Date Recei t#
V agalest liabilities,jodgmentacore.nde.penses which may in anywayamrue AIR HANDLING UNIT CTO I0,O3O CFM) SUBTOTAL;
hga Id City In..met the ening of this permit. AIR HANDLING UNIT(OVER t0,WOl7FM) _ CONSTRUCTION TAX
Sig(/roof Appicant/ o of Date• . EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZAR S MATERIALS DISCLOSURE
Will the applicant orfeturebuildingoavpant store or handle hazardous HEATINGUMT(TO100,000BII) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
I lealth and Safety Codeict*12-S32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 7�
yeso
Ill the appileant or future building occupant on equipment or devices VFNII LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harzrdous ale contagsieArt.as de0ned by the Bay Area Air
. Quality Management Dis BOILER-COMP DHPOR 100,000 BTU) ®a
Yes o
the read the lious materials requirementsunder Chapter G95mf BOILER-COMP(OVaIC0,000 BTU)
the Ca llfomia Health&Safety Cade,Sections 25505,25533 and 25534.1
understa rad that if the building does not currently have a tenant,that it Is my NEW RESI DENTIAL MECH. SQFT
responsibility to notify the occupant of the requirements which must be met
prior to i toe ce of a Certificate o cep a
Ownero thodred agent - Data TOTAL: ISSUEDBY:`J `•
OFFICE COPY