19914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 1991 4
10S,5- NoQe_m 3 2
n Phone: A A
CITY OF CUPERTINO-BUILDING DIVISION
Contra ore Name: L(c.No: APPLICATION / PERMIT
0 �' BLDINGM
ELECTRICAL-PLUMBING-MECHACAL CATEGORY CONTROL N
Archkm/Engineer. Lk.N. Uf
QTY ELECTRIC E IT r,, FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE '(a ❑ ❑ ❑
LICENSED Reamed nderE DECLARATION (( h
I herebyaffirm70that l amlicrnsaftheBuinemannsoffes ponr9(commmc- APPWANCFSRF3IDE 70B DESCRIPTION
ingwhh Section 7000)offAvlslon3o(the Buslnesaandl'rolmponaCpdc,and my (ay/ � ///JJJ��-��✓✓11""
PANFTS ✓Y9 f-�Y
limnu la In(ujlJ ddfect. l
License Clxs_l�ae- Cour N_��„SQ�j_
Data—IFL� Contractor DECLARATION�s'-E�— 201-10DOAMI
ARCHITECPSDECLARATION
�
SI CA
7 ]understand my plans shall be used records.public rerdrecords. OV 1 [5 SQ.FT.FLOOR AREA 5/SQ.F7.
ZO TR
LlmnsM Professbnal
<D. OWNER-BUILDER DECLARATION CIR TSC
1'�.7i Iherebyaffirmthat l amesempt fromthe Contractor'sLicanee Lawforthe
following reason.(Section 70315,Business and Pmfenions Code:My city or ',MECER OR POLE SE.
countywhich requlresa permit tomnstruct,alter,Improve,demolbh,orrcpair
anystructure prlortoitsissuamc alsorNui theappBrantfwsucb permitto �D ES
file a signed statement that M b Iimnaad pursuant to the provislom of the
pOw Contractor's Liceme Law(Cbaptar9(commd
enngwithSeniors700ofDivl-
0)
Yon3ofthe Businessand Profevlom Code)orthathebeaemptthemfromand SWIM POOL I;L I0C VALUATION
E, si
the basis for the alleged exemption. Any violation of Section 70315 by any c
p
applicant for a permit subjects the applicant to a civil penalty of fiat morethan OUTLE4SBWITC FI17l)RFS
five hundred delta.(S.50M. NEW RESIDENTIAL IAZCTR
�?6 c❑I,as owner of the property,or my employees with wages as their solerystrucstructure b SO Fr. STORIES TYPE CONSTRUCTION
pensatlowllldothaovork andtbe asnorIntended or offered for
5�J ❑ vie(Sec.70K Bess m usinand ProfessiaCode:The Contractors License law
does not apply to an owner of property who bunds or lmproma thereon,and OCG GROUP RES.UNITS
who doessuchwork himself orthrough hisownempirryees,provided Outsuch
Improvements;are not intended oroffered for sale.IL howevcq thebullding or TOTAL
Iprovement b sold within one yearofcompletlon the owner-bullderwlll have
lzatlurdeo of proving that he did not build or Improve forpurpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed ppzMRLSSIJANCE
contractors to construct the project(Sec.706A Business and Professlom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
builds or Improves thereon, and who contracts fee such projects with a FEE SUMMARY
C'N.ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this reason
OUTSIDE FLES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIPTM
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
M1 hereby affirm the I have a certificate of consent to self-inmre,or RECEIVE N
certificate of Workers'Cump osatlonlmurance or a certified copythemof(Sec. GAS EA.SYSTEM-i INCA OUTLEES PARK FEE Y N
3800, ab
Policy Y ���C` RFLFdPC X
Comnanv 4i0// f(a[,_-- inial GAS EA.SYSEFA4-0VERY(EA) BUILDING DIVISION FtF.S
C
enifted copJbhereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
MCertified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FE Date Recei t#
(1'hiasenion need not be complsed If the permit is forone hundred dollars
(Slm)orlan.) WATER HEATER W/VENT/ELLCTR ENERGYFEE Y_ N_
I certifysv
that in the performance of the work for which this permit is bed,
I shall not employ any peraon In any manner so as to become subject to the WATER SYSEPN/TREATING PAID
Workers Compensation Laws of Califomia.Date
O Z Applicant NEWRESIDEtMALPLMB. SQ.FE. Date Recet#t
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workeri Comperuetlon provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE d0
deemed revoked.
W � CONSTRUCTION LENDING AGENCY SEISMIC PEE
d I hereby affirm that there b a construction lending agency for the perform TOTAL ELECTRIC FEE
Z anon of the work for which this permit b Issued(Sec.3097,Civ.C.) PLUMBING FEE
(� O Icndds Name
LL ~ L imam.Add.. QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
W 1canifythatl havereadthisapptiotionand statethattheabovelnformation
Oa
4 bounces.I agree to complywlth all city and county ordinances and pate laws PERMITISSUANCE FEES PAID:
>_ (L to building construction,and hereby authorlu representatives of this
I— Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Dale RfCCIPt#
_ (We)agree to save,Indemnify an d keep barrel.the City of Cu pertinu AIR HANDWNC UNIT 8010,000 CFM)
against liabilities,pdgrrcnta,coexpe pea whichmay litany wayaccrue SUBTOTAL:
agar w City InEr
of �, to a enn ' CONSTRUCTION TAX
♦//IO �I AIR HANDLING UNIT(OVER 1BE00CFM)
Sig eo(AppllDate IXFIAUSE HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATERIALS DISCLOSURE
illlha applicading occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Recd t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the
Healthand5alcty Code on 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: l
F-1w
Yea o
Will the applicant or town,building ompantuseequipment ordmices VFN7ILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air conlambunb as defined by the Bay Area Alr kk��
• Qi Illy Management District,/? BOILER-COMP l311POR 100,000 BED) —A
4yen
havemad the bazardousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the California health k Safety Code,Sections 25505,75533 and 255M. 1 I• 4 (1 I'J./
senders that l(thebulldingd of currently have a tenant,that it k my NEW RESIDENTIAL MECH. SQ.FT.
res rib ity to notify the oc ant Ith requl fits which must be met
p orto uanceofa Ce2Ri teof a/, cityOfrlil('n'rfin
er or authorized agent �6ate V ISSUED BY: �+✓ t�
TOTAL:
OFFICE COPY