23312 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuildingProm Identification PERM]T NO.
Building Addre
Buig ss:
1980# -0 /02- 2331
wners 1 q.res: /� once:
S C 6& Cr CITY OF CUPERTINO-BUILDING DIVISION
Conor'aNamr it j LIc.N. APPLICATION /PERMIT
AWL C41?S Ef NN✓1 I e Z27 B LDINGELECTR CALFLUMBINGM[CHAMCAL CATEGORY CONTROL Y
Architect Engineer. LIB No:
QTY ELECTRIC PERM TT PEE BUILDING PERMIT INFO
Ad Ther PERMITISSUANCE ❑ "/"
LICENSED CONTRACTOR'S DECLARATION Ihth5yiOR7000)ffirm tlamllcen3.fthdurnemand Proessims9(mmmrnc APPLIANCES-RESIDENTIAL JOB DESC ON
Icarse11.fan foreanDivfect. o(the Budneumdlsrofeadona Code,and my
license bin full force and effect PANELS
Ll a Clss Lic'CH M� r`'7NC�'e�eJ
Dale�. U�Contnno L 49 2UP 01 TO2AMP$
ARCHITE be
WRATION SQ.Fr.FLOOR AREA S/SQ.FT.
IQ+�0 oCC I understand my plan shall be used a,public records. OVER 1000 AM PS q L E D I N
E o U Licensed Prolessio al SIGNS ELECTRICALMTN
dddd 6 OWNEReBUILDER DECLARATION UTE R
Yrs 3 SPECIALETEROR POLE /
7e, owing um.(hrtlamexemptfromthe Contractor's License Law fort he
qqqqqq following reason.(Section 70315,Business and Professions Code:Any cityor
Fs' county which requlma permit foccrstrun,alter,Improve,demolblimropalr TEMP,MEITRORI'OLE INST.
5 an YID
ystmmmpHortoit.issuance,alsorvpir iheappUcantforwchpermitto DATE
file a signed statement that he Is licensed pursuant to the provbioM of the POWER DEVICES
3 w Contractors License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
IS Con3olthe BusinaWro
sand ProtessCodb
e)orthat he VALUATIO��
the bash for the alleged exemption. Any violation of Section 70115 by any O `('J�GJf
OUTLETSSW17CIiFSIgX'NRFS
p applicant fora permit subject@ the applicant to a civil penalty of no mum than U
�j five hundred dollars(SS00). NEW RESIDENTIAL ELECTS(d?gra ❑I,as owner of the property,or my employers with wages as their wk SQ'FT' STORIES TYPE CONSTRUCTION
mmpenudoo,will do the work and the structure is not Intended or offered for
0 ale(Sec.7094 Business and Pmfmmm Code:The Contracioes License Law
does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RES.UMTS
whodoessuchworkhinsel(orthrough hbownemployees,provided that such
Improvement are not Intended orofferN lwule.IL however,thebuilding or TOTAL:
improvement lasold withlnoneyearolcompleliogtheownenbullderwill have
tl)Rkurden of proving that he did not build or Improve for purpose ofukJ. QTY. PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
contractor,to mrt.tmct the Project(Sec.70K Business and Pmfesd..Code:
The Contractor's License Law does not apply to an owner of property who ALTERDRAIN k VENT.WATER MA)
or Improves thereon,and who contracts for such projects with a
as
r9n4.nor(.)Bcensed pursuant to the Contractor'.Lim.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJl am exempt under Sec B k P C for this mason
DRAINS FLOOR ROOF,ABTA,COND. SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION pp(TURpg pgg TRAP SCHOOL TAX Y N
❑I hereby All.rkn that I have•mrt... of consent to c,pytham,ora RECEIPT Y
certlllale of)Work[en�'Comperuetlan lrsunnm cera certified copythemof(Sec, GAS EA.SYSTEM-1 INCAOUTLErS PARKFEE Y N
3YOO,Lab CI RECEIPT#
Pu11ry GAS EA.SYSTIM-OVER 4(EA)
' Com nv. •A ,�S J _ BUILDING DIVISION FEES
�crtlfed copy b bed with the
—1�— CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
'1-4Cert1(led copy k(fled with the tlty inspections division.1� CERTIFICATE OF EXEMPTION FROM WORKERS' GREA'SE7RAP PAID
COMPENSATION INSURANCE
(rhlsenctlon need not be completed if the permit is foram hundred dollars SEWER-SANITARY-STORM FA.20017. Date RCc21 t#
(5100)w les..) WATER HEATER W/VEM/EL[CTR ENERGY FEE Y N
I certify that In the performance of thework forwhlch this permit is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
-
Z Z Applicant NEWRESIDPI-MALPLMB._SQ.FT. Da9e Reeel f#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should be..subject to the Workers'Compeuat Ion provisions of the Labor TOTAL:
N Code,you corset forthwith comply with such pmvbWm or this perrrdt shall be BUILDING �^
W > dimmed revoked.
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
M Z anre of the work for which this permit b Issued(Sec 3097,Civ.C.) L0 �"'�
V O Landar'.N.me PLUMBING FEE 1
IL F Lender's Address QIYII MECHANICAL PERMIT FEE MECHANICAL FEE .
Ol certifythat I have readthis appllatlonand Catethattheabove Information
lU Lsoarren.l agreeto comply with a0 cityand county ordinanres and Cate laws PERMITLS5UANCE FEES PAID:
>. N relating to building mutruction,and herby authodee representatives of this
F Z city to enter upon the abovcmentknad property for inspection purposes. ALTER OR ADD TO MECH. Date RCCCI C#
— (We)agree to ssve,Indemnify an d keep harmiess the City of Cu pert loo P
agabst lkbllltles,jidgmenb,coca ands penseewhlch rtuy In anywayacrne AIR HANDLING UNIT(r010,000CFh1) SUBTOTAL:
agalmte in con.aquena t an tingofthlapermlt.
aZ AIR HANDLING IIfvTf(OVER IO,OW CIM) CONSTRUCTION TAX
Slgnumo Applicant/Comractw ���`--/Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIltheappBa rat orfuture building occupant store or handle havardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and thein sol=p"
f❑alt,and Safety Cade Sectioon 25532(a)7 HEATING UNIT(OVER IDD,000 BTU) TOTA .
Wlllthe applicant w7Tlum building occupant use equipment ordevim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaenndnt I t ict?aminants as defined by the Bay Area Air
ality Marugement Dblrin7 BOILER-COMP pFm OR 100,000 BTU)
Yesn❑No Y F9
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,00(1 BTU)
the California Health&Safety Code,Secilou 75505,25533 and 25534.1 ���
understand that if the building does not currently have tenant that itkmy NEW RESIDENTIAL MECii. SQ.FT. ��
reaponsibllity to notify the oocupant of the requirements which must be reed Iy
p�rior/to_J�a.�y//ono,of a a Certificateo(Q paancyy..�� -s: CITY Ur wl'tnluvu
n(M sr.K. orimlTi d lent dill" �t"
TOTAL: ISSUED BY.— Y
OFFICE COPY