20809 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PLRMITNO.
Ifuil7i ofd mss: Q 2 0 8/- I 0 9
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me: one: p
y2y/N CITYOF RTINO-BUILDING DIVISION �j " C )1
Contracte.Name � /JCrI� Lk.No. �i��AtZATION /PERMIT (— 2ib CC U
I� Q--)-75, 1 /4 A al "-'y -U1,&-R�GN �gTJILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N6/
n'e r(�/1P a1� ^ Aa Lie No. BUILDING PERMIT INFO
/� /'7 p�? QTY ELECTRIC PERMIT FEE
Address: ?I 4! L-AM/ 1?4r LG •- PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION 7-=��TL/��
D 11
Ihereby affrmthat Iamllcensed under provinionnof Chapter9(commenc APPLIANCFS-RFSIDENTIAL TOB DESCRUMON
Ingwith Section 7000)of DiAsion3ofthe Businesaa dPofessionsCode,and my
license Is In full fyyy me and effect y �u / PANELS
Llrense Cyse Lk.p G
Date O - Contractor UPTOMOA
ARCHITECT 5 DECLARATION 201-10DOA.MPS 11 -AVr% M
X I understand my plans shall be used as public records. .OVER 1000 AMTS 91141SQ.FT.FLOOR AREA f/SQ.Fr.
fiLicensed Professional SIGNS ELECTRICA�tAY
M -7 g Z
OWNER-BUILDER DECLARATION If
SPECIAL CIRCNT/I,SLSCv (, •IY
IherebY affirm that l am Pt
exem from the Contractor's License Law for the _ a'
a
yr
following mason.(Section 7015,Business and Professions Code:Any city or
TEMP.METER OR E IfJST.
p countywhkh rcquircaa permit tocor;trud,alter,Improve,demolish,or repair
_
ri?1� a anydructure priertoits Issuance,also requirestheappBont forsuch permit to - POWER DEVICES
licensed / 190.
OOCFV ilk a signed statement that he is censed pursuant to the provblom of the
m Contractor.License Law(Chapter 9(commencing with Section 7000)of Dlvl-
Off'
to.3ofthc Beulnessand Professions Code)orthat hole eVALUATION
the
therefromand SWIMMING POOL EL"C
Sthe basis for the alleged exemption. Any violation of Section 70315 by any 6 OU LETSSWITCHES ES 4. V i � DO
applicant fora permit subjects the applicant too dvil penalty of not mure them
five hundred dollars(SSW).
{{{yyy NEW RESIDENTIAL EL SQ.Fr. SFO TYPECONSTRUCI'TON
. 7 ❑e as owner of the property,or he employees with wages r their sole
compensation,Boedsxtheworkdessie,Code:
Vnotintendedo ioffered(or
Osale bee appy to alnesaaMf property
who
Wilds or Improves
License law
(;j$$ does not apply torn owner orthreu h who nem orees,pr provided
at and such OCC.GROUP RES.UNITS
EE
whoroves encsuch am not
tInten edorough his owneered for .11,hoes, er,the uildleger
Improvementsared withindncycar fcompletion lf, owner-p deer il)have TOTAL.
Improvement bsold within oneycarofcompietlon,theowner-bulderwlll love s
tlA.Ifurdeo of proving that he did not build orimprove for purpose ofsale.). Qry. PLUMBING PERMIT E
F1.00D]�NE APN
LJ
I,as owner of the property,am exclusively essanding with licensed PEW
ISSUANCE
The Co on to coLicense
the project(Sec.appy Business and of property
rt Code:
TM Contractor.License law does not apply to an owner of property who AL RAIN&VENT WATER(EA)
Wilds to Improves thereon,and who contracts License
plojem with a FEE SUMMARY
c actor(sexemlicensedunder Snt to the Contractor's Lk ense Law. BACK PROTECT.DEVICE
LI I am exempt under Sec. B k P C for this rc
aron
Owner Date DRAINS FLkF,ROOF,AREA,COND SANITARY Y_ N_
RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES. SCHOOLTAX Y N
❑[hereby efflrm that I have a certificate of consent to self-Insure,ora RECEIPT N
/ certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS F.A. IllNC.p OITIL PARK E: Y N
38 W,Lab C.) RECEIPT#
I ollcy p CAS EA.SYSTEM- H p
Com any - - BUILDING DI VISION Fr.ES
�Certl(Ied copy is hereby furnished. CREASE/INDUST'L AS/INTERCEPTOR PLANCHECK FEE❑Certified copy b filed with the city Wpecdon division. bre- 71
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP A PAID
COMPENSATION INSURANCE SEWER-SANITARY FORM .200FT. Date ReceI tit
('Thissrahm need not be completed ifthe permit Is forone hundred dollars
(SlW)orlessJ WATERHEAT W/VFNP/ 1R ENERGYFEE Y_ N_ SD
Im.rl that In the permu
(ounof the work(orwhkhthls permit blasved, - ,
I shall not employ any person in any manner so as to become subject to the WATER /TREATING
Worken'Compensatlonlaws of California.Date - PAID -
0 Z Applicant - NEW DENTIAL PIMB. FT. Dale Recei tN )
Z O NOTICE TO APPLICANT:IL after making this Certificate.f n,you
should become subject to the Workers'Compensation provi9loraofthe Labor - TOTAL:
Fy Cede,you must forthwith comply with such provisions or this permit shall be - s4)
1119-71
LU > deemed revoked. BUILDING FEE
LU
a CONSTRUCTION LENDING AGENCY . SEISMIC FEE c
Z Ihereby affirtnthat there is a construction lending agency for the perform- _ TOTAL: ELECTRIC FEE LvD
7 ancc.fthcw.rkforwhtchthix permit Is issued(Sec.M97,CIv.C.)
U O lenders Name PLUMBING FEE
F- Londer.Adares. QTY. MECHANICAL PERMIT FEE
Ow Ireniythatl"vemadthisappliationandstatethatsheabove Information MECHANICAL FEE
1 is correct.I agmeto comply,wnh al cityand county ordinancesand state laws PERMIT ANCE FEES PAID:
} relatingtobuilding construction,and herebyauthorize representatives ofthls _
H N city toenterupon the abovcmentkmed property for inspection purposes. ALTEROR DD'IOMECH. .
Z (We)agree to save,indenudfy an d keep harmleasthe City of Cupertino Date RCCClPl#
V against liabilities,judgments,costsand expect Id may In any way accrue AIR HAND CIINIT(TO10,000CFM) SUBTOTAL:
agalnst,.apld Clty In con.equenceofthe gran ofthis permit AIR HANDLIN UNIT(OVER 10, FM) CONSTRUCTION TAX
(/•l�fJ7e�4a Q
SlgoatureofAplicant/Contrader Date D(HAUSTHOOD /DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea (cant or future building occupant store or handle hazardous HEATING UNIT(TONVO BTU) -
PP B Pa^ Date Recei Ipf
materia not Safety CodeSCupertino Munldpal Code,Chapter 9.12,and the
Iicalth and Safety Code Section 25532(.)7 HEATING UNIT( W,000 BTU) TOTAL:
❑ Yes ,La-y�N-`'�o
Will the a ppliant orfBture building occupant use equipment ord evices VENTIIATI PAN(51N .E RESID)
- I$$U CE DATE
which emit hazardous air contaminants as defined by the Bay Area nsAire
Quality Magement District? BOB. U)
OMPQHPOR1 BT
4Yes
have read the bmar us materials requirements under Chapter 6.95 of BO .'R-COMP(OVER iW,O eTU) ry �rs ss/ Q
the California Health A Safety Code,Sector;2550.5.25533 and 75534. 1 A 1990
understand that if the building does not currently have a tenant,that it is my RESIDENTIALMECH. SQ.FT
mspordbillty to notify theaccupant of the requirements which must be met .a
prior to Issuance of.Cc a to ofoc.pxny. City of CpR?rtino
OMkr or thoriced agent Date . TOTAL: ISSUEDBY:
OFFICE COPY