20475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIRMITNO.
B"Ilding Address: 20475_
101 ooember by-,
nets ams: o A A A
E a 7_Cta CITY OF CUPERTINO-BUILDING DIVISION ^�O
Cnntn70' Name: / // ue.Nn: APPLICATION I PERMIT J l
F/Sf.1A'Q'Y f�GLm61/I4 `I" LT//'la 33S68� BUILDING-ELECTRICALPLLTMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lic.Na
BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Addmss: s,—ar ❑ ❑
PERMITISSUANCE IIIYYI
LICENSED CONTRACTOR'S DECLARATION
I herlrmthatlam licensed under provisions Cha(m,mmenc- PLIANC6RFSDENTIAL JOB U[SCiII710N
'ngwithSection 7000)ofDlWpon3ofthc8upneu;and Pm ocaCdeand
my
licetue bin to forcey� dfeR. P
License Class '/C Llcp '
Date t 72w Contractor __UTO AMES
ARCHITECTS 101-1000 PS izeto Tp wsml h 34TNQo
O Z I understand my plans sha l i e used as public records. —OVER100ONZALS SQ.Fr.FLOOR AREA
�qqP! O
E E°i�j Licensed Professional SIGNS ELEC L
Q OWNER-BUILDER DECLARATION SPECIALCEtCNL
1,,, IhercbyafRreithatlamexemptfromthe Contudor9Llcenselawimthe
7. following reason.(Section 7031.5,Business and Professions Code:Any city or
O�i:. P.MFTFRO L INS . 1
countywhich requires a permit to construct,alter,impmve,dernoled,orrepair
qY .a anystrocture prior to its issrance,also requinestheapplicant for such permit to PO DE-NEC
66 c4 y R4 a signed statement that he is licensed pursuant to the provbdoes of the
Ore Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
30r^ pon3ofthe Businessand Pro(cmbmCode)orthathebexem therefmmand SWA1 NG VALUATION
the bush for the alleged exemption. Any violation of Section 7031.5 by any OLM ES
�ry¢+ applicant for a permit subjects he applicant a civil penalty of not morethan
c.LL5y o five hundred dollars(4.500). qty R p�.pg �.
I as owner of theproperty,or 1 swith wa as their sole '1' TYPECONSIRIICTION
z�+ c O, my employees great
ompSce.70 n,wW do the work,and the structure Isnot intended or offered for
' o rale(nec.apply
tB..Eraas
owand f property Cade The Contractors License Law
$ does nonsuch torn owner ofpropertywho builds
mpicymprovothereoM and
S^
who doessuch work himself orthrough his own employces,provided that such OCC.CROUTa RFR.IRJITS
impmvemenh ate not intended oroffercd for vie.IL however,thebuiWing or TOTAL:
impmvementissoldwithinomyearofcompldWn theowner-bu8derwillhave
t"iden of proving that he did not build or improve for purpose ofsals.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively wroracting with Romano PERMITISSUANCE Ml`�
contractors to construct the project(Sec.7014 Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pSojects with a
�qWf+ctoKid licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this mason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP � SQ100L TAX Y N
❑I hereby affirm that I have o Insurance
of consent to pythereo or t RECEIPT#
3800,LaL^ol Workemi Compensation Wunnre ora recti(led copyhemaf(Sec. GAS EA.SYSTEM-1 INCAOLHLETS PARK FEE Y_ N
Policy
lab CJ RECEIPT#
Pollry#cGAS EA.SYSTIN-OVER 4(FA) BUILDING DIVISION FEES
ra�mpy
�_1Zert8led copy b hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Canertified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORK EA.20OFT. Date Recd t#
(Thlssectun need not be,completed J the permit b forces hundred dollars
($10))or l.') WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I mrtilythat N the pnpormanre o(the work(or which this permit Is Ivsved,
I shall not employ any person In any runner so as to become subject to The WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
OZ Applicant NEWRE4DENTALPLMe. SQF. Date Recei tl<
Z O NOTICE TO APPLICANT:It,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compensat Ion provedons of the Labor TOTAL:
I— N Codi,you most forthwith comply with such provisions or this permit shall be BUILDING sV
j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a ° Thereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z an of the work!or which this permit Ls Issued(See.3097,Civ.C.)
U O Leader's Name PLUMBING FEE (w
ly F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ]certilythilthis a mad this application and statethatthe above Information
d 0cormct.Iagree to comply with all city and county ordinances and pate laws N PERMITLSSLIANCE FEES PAID:
>_ fA rclming to building ronstruNon,and hereby au orfze representatives of this
F city toenterupon hn above-nrntloned pro p° forinspectlon purposes. A TER OR ADD TO MECH.
? (We)agree weave,Indemnify..d keep armless he cityof CV pertfrw Date Receipt#
U against liabilities,judgrrenb,cop Id e;"
a whlchmaylnanywayicerue AIRt NDLNGUNiTaolo,Ooli SUBTOTAL:
agaWtsaid Ciryl he gr ting of this permlL AIRHAN NG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
J
Sigwturc of App cant omrador Datc IXHAUSTH DEW/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wkilasl the appliclefinearat the r future
mind ng Municipan wide, h handle h andthe HEATING UMT 100,0008TIp Date Recei til
Heals el as defined by the Cupertino Municipal Cede,Chapter 9.1 1,and the -
HealthandSufcryCod�le+JSMlon 2553Xa)7 HEATING UhTT(OV loo,REo eTN TOTAL: (61 Sb
MY.
Will he applicant or tutvebullding occupant use equipment ordevices VFNIILATION FAN(Sl ERFSN) ISSUANCE DATE
which eManavminrAD air find? wntsade8ned by the Bay Arca Alr
lily Mansgcmcnt District? BOILER-COMP pHP OR 1W, BTU) PA
Lj Yes ❑No D
Q�ja haifomUHealih&doos0teHnajl'mquimentsunder Chapter&95ofBO3LFR-COMP(OVCRIW,OWBtheGlve reaHealth&Safetyme 125537Ch.per& 1Y (junderstand that if the buildintly have a tenant,that It is my NEW RESIDENTIAL MECH. .FT { 2rsponsibllltytongif lrcments which musthemetprior to ixu o e can�`J
Owner o autho - agent Date TOTAL: ISSUED BY:
OFFICE COPY