23706 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Probe idemi(imtianPERMIT NO.
Building A,vd�dress: /� ��I/1/����/��}��J� „-„-,- f•l 23706'
1/"t70
w came: one: _...._APPLICA A . �...
� CITY OF CUPERTINOL6 ILDNG DIVISION �t �,..� /))�
Contractor's,Name:- Lic.No: APPLI•CATI EMIT
BUILDING-ELECTRIC' UM BINGMECFIANICAL CATEGORY - CONTROL#
��Fdtect/Eng!neer., _ .Lk.Ne:' ..
QT'Y-- BEE RCPP.RMIT --FEE' BUILDING PERMIT INFO
Address: TI CE '!
LICENSED CONTRACTOR'S DECLARATION -- --•- - •^- -•-
I hereby affirntham licensed l alicensed under provisions,of Chapter 9(commero ESRESIDE 1 ^ JOB DFSCRBxr10N
license I,
form
inSection and
effcn3ofthe Businessand ProfessionsCode,and _I lO ^ 1
Llanse Class Uea •”.-...� ••• •" •� �• '
Date Contractor
ARCHITECPS DECLARATION 201-1 I
ntOp I understand my plans shall be used as public records OV 1 P& ..•..^....`-_•-•. . . - SQ:FC FLOOR AREA 5/ �
PQM SIGN GL ^L
Ft LkensM Professlonl . . '"'1111
G�<�? OWNER-BUILDER DECLARATION SPEC CIRCUIT/MIS1`
] 2 1hereby affirm that l am exempt from the Contractor's License Law for the
-oo following rea+on.(SMlon 7031 S,Business and Professions Cade:Anycity or
Ozs'u9 county which requima permit tocontrue,alter,improve,demolish,ormpair P.METER OR TOLE[NSI'. - •., „ . ,- _
�,SJ� anystmcture pdortolb Issuance,also requires theappliant forsuch permit to POWER DEVICES
file a signed statement that he is Iimnsed pursuant to the provisions of the
Contractor's License Law(Chassme
er9(comncin with Section 700D)of Divi- W
F• OS koo3 of the Businessand Profe
ssime,Code)or that he is exemWhemfmm and C ELECTRIC-•ss •' VALUATION
V 4,1-, the basis for the allegt$l exemption. Any violation of Section 7031.5 by any
applcantfor a permit subjects the a pplicant to a civil penalty of nU more than - TCfdESH),nRd' _� ii
ecu ppp6S�,,, five hundred ollars(5.500). R B L
1,as ownder of the property,or my employees with wages as their sole STORIES - TYPE CONSTRUCTION
c mpensatlon,willdo the work andthe structure is not intended or offered for
Osale(Sec.7044,Business and Professions Code:The C.etractols License Law
F7j $ does not apply to an owner of property who builds or Improves themes,anA DATA' --Gec.caolm RES.UNITS
who doessuchwurk hirseRurthrough hisownemployees,provided thatsuc
improvements arc not intended oroffered formic.If,hcwevep the building or
improvement band withinomyearofcompleion,theowner-bu0derwill have '•"
irys.pnrdenofprovingthat he did na build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE AT DZONE APN
fl"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '
contractors to contract the project(Sec.7044,Business and Pro(e ekom Code:
The Contractor's License law dm no apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) r•
ALTER-
builds or Improves,thereon, and who contracts fee such ptojed.with a FEE SUMMARY
�gLJ Wfactor(s)licensed pursuant to the Contractor's Lima.Law. t BAIX FLOW PROTECT.DEVICE �.•+•-
1 am exempt under Sec. B k P C for this mason
DRAINS FLOOR A;ROOF,ARECOND. SANITARY Y— N—
.Owner Data RECEIPT If
WORKMAN COMPENSATION DECLARATION FIX'fURFS PER TRAIT . .•- l SCIiOO TAX Y_' N
-.thereby affirm that I have a certificate of cement to self-losere,or RECEIPT#
�cedl0cate of Workers'Compenation lnuranre or a certified copy themof(Sec.
PARK Y380D,LabC0 CAS EA.SYSTEM-1 INCA OUTLETS N
—
.. p
-Policy# RECEIPT
GAS EA.SYSIE OVER 4(EA)
Com y - BUILDING DIVISION FEES
ffCanomfiel copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ,,y^^
Certified copy is filed with the city Inspection division. — i
CERTIFICATEOFEXEMPriON FROMWORKERS', GREASE TRAP PAID {i
COMPENSATION INSURANCE I
tel. ,
TThisectionneed not be completed if the permit is forone hundred dollars SEWER-SANITARY-STORM EA."FT. '-•Date
(4100)arlmJ WATER HEATER W/VFM'/ELECTR ENERGY FEE Y—I certify that in the performance ofthe work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compenation Laws of California.Date PAIDOZ Applicant NEW RF9DFMIAL PLMB. QFT. Date
Z O NOUCETO APPLICANT.IL after making this Certificate of Exemption,you _... _.
should became subject to the Workers'Compensation provision fthe Labor T
N Code,you most forthwith comply with such provisions orthis permit shall be
BUILDING FEE
revoked.
W > deemed CONSTRUCTION LENDING AGENCY ....,.. �.^ ... ...... SEISMte'PLE-^-- "-
a ° Ihereby af .that there isa contraction lending agency for the perform TELECTRIC FE•
M Z anmofthe work forwhichthis permit is issued(Sec.3097,CIv.C.) —
V O Lender's Name , P,LU _
LL F Lenders Addem QTY. `MECHANICAIL'PERNDT -' FEE CI LEGE
O W Icedlfythatl have rcadthb applicatlonand statethat theabove Information .
is cormct.lagreetommply with all city and county ordinances and s,bte laws PERMIT ISSUANCE F
It. relating to building cuntructin, tui hereby authorice reprexntaif ofthis --� -- —"'- s
F N city to enter upon the above-mentioned property for Inpeeionpurposn. ALTERORADDTOMFCFLIR
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against llabilltks,judgments,mets and expenses which may in any way accrue AIRFANDLING UNIT,{TOIQO)O CFM) ..-_..__.-__-..__,_,SU TOTAL:""
_ _
aga Wt mid City in mmequence of the granting of this permit.
AIRHANDLING UNH(Q VER 10,000 CFM) CONSTRUCTION X
Signature of Applicant/Crntraeor Dale EXFLAUSTIIOODtW/DU(777 - CONSTRUCTIONX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or ha rad le btuardous HEATING UMT.(TO ID0,000 BTU) Date ,•,,,�
• material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
health and Safety Code Section 2SS39(a)7 FiFATING UMT(OVFR 100,000 BTU) •I•MVP%
❑Ya �No
Will the Spplicant or future building occupant use equipment or devils VENTILATION FAN I.SINGLERESID) - _
which emit havrdous air contaminants as defined by the Bay Area All - `�
ality Management District?, BO[LER-COMP(31-1P OR 100,"BTU)
Yi' ❑❑No '
y: 'cmadthehaz dOusm tedais requiremenb undcrC wpter6.95 of MOILER-COMP(OVEt100,000 BTU)-- _._ -171)"
t Califom!a Health&SafetyCode,Sedion25505,25S33and25534. I -
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FF. n'
nsponibility to notify the occupant of the requirements which most be met
.. ...... .. ... ru l��
-prior to Issuance ofa Ccrtlfkatc of Ocmpanry. " 'y
• - (rallvr ... Ih
Ownerorauthon.dagent Date ISSUEDBY' 111yu
r'
OFFICE COPY'