19690 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro'ed identification PERMITNOO.
B — —� 19690
/4!V0p
�4/C
wners ante: hone:
CITY OF CUPERTINOBUILDING DIVISION O�
C °rt°'' c'N ' OF
/PERMIT
I'� BUILDINGELECTMCAGPLUMBINC MECHANICAL CATEGORY CONTROL S
Arch tett/Engineer.
Lk, a:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lent llemeed underpr°vlalans o(Chapter9(comment- APFLIANCFSFESR)ENML JOB DESCRIPTION
ingwilh Section 70M)of DiWsion3ofthe Bugnessand Pmfea m&Code,and my s
Ilam is in o d effect. PANELS
Liars LI[.N
Da ContnRor
ARCHITECTS DECLARATION ��/�/ 201-1000 AMPS a/' M� 1/
�2 understand my plans shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR EA sm.n
CCO
(s Licensed Pmfeniowl SIGNS ELECTRIC
OWNER-BOLDER DECLARATION SPCCIALCRCU(T/
7p, Iherebyaffirm thatlam exemptfromthe Contractors Licenee Law forthe
following reason.&ofon 7071.5,Business and Protestations Code:An city or
c°untywhlch mquircsa perMttommtrucl,sling Unpmve,de^nlbh,orrepalr P.METIRO ST.
q� anysbueture pdorlo its Issuance,also mquiresthe applicant forsuch permit to
E5 'ilio a signed statement that he is licensed pursuant to the prov eloru of the DE1�
W6 3 O ContnRor's License Law(Chapter9(commencing with Section 7000)of DlvI- 5 N ELFC
s., al.d3ofthelftme ss.ed PmE.EdaCade)orthal hebexemp[Iherefromand VALUATION
F a the basis for the alleged exemption. Any violation of Stolon 70115 by any OUTL TC ES
OA applicant for a permit subjects the applicant to a civil penalty ofma rnorethan
five hundred dollars($500). W D .L glCq
_—SQ,FT. TYPE CONSTRUCTION
�. ❑I,as owner of the property,or my employees with wages as their sole
C < compensation,wWdolhe work andthe structure b not intended or offered for
q sale(Sec.7044,Business and Pmfessi°m Code:The Contradoes License Law
does not apply to an owner of property who builds or improves thereon,and OCG GROIII' RE'S LINERS
who doessuchwork hienself.,through hlsown employees,provided that such
Mprevements are not intended oroffemd forsals.If,however,the building or TOTAL:
Improvement la sold within one yearofcompletion,the owner-bWlderwill have
the burden of proving that he did not build or Improve for purpose°fsale.). QTY, PLUMBING PERMIT FEE FIppDZONE APSE
0 L as owner of the property,am exclusively dentraeing with limned PERMITISSUANCE
centractom to consWR the project(Sec 701y Business;and Professions Code:
The Contractor's License Law don no apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Imprwea thereon, and who contracts for such pPJects with a
c�}R�acoKs)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_I I am exempt under See. B&P C for this rcaa°n
•
OUTSIDE F
Owner Data
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N RECEIPT
M
WORK MAN COMPENSATION DECLARATION FTXTURRES PER•TRAP SCIfOOL TAX Y N
❑I hereby affirm that T have•certificate of consent to oself-Insure,themof or a RECRRH,N
certificate ofWorkerr;Comperuatl.nlwuranaora artifled copy themof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
2aCJ61L n(�?// �E
po0olirypb L• �ZO�'.�7�( RECEIPT
Com any O GAS�EA.SYSTRM-OVER 4(EA)} I e2reby famished.
aI��1 tlU1LDING DI VISION FEES
Certified pyB herebyyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy V filed with that city inspection division.
CERTIFICATE OF FXEMPTION FROM WOR KERS' GREASE TRAP PAID
CN becom
COMPENSATION INSURANCE SEWFR-SANITARY-STORM EA.200FT. Data ROOCI t#
(Thio session need nat becompleted it the permit Vlorone hundred dollars
(E1110)artily that
WATER HEATER W/VENT/EEECTR ENERGY FEE Y N
Ihat In the performance olthe work f.rwNch this permit b Issued, —
I shall not employ any person in any mad.,ad,u to be..subject to the WATER SYSfCM/•I•REA•IING
Workers Compensation Laws of CaB(omla.Date PAID
0 Z Applicant NEWREMDENTIALPLMB._�.Fr. Date Revel t#
Z O NOTICE TO APPLICANT.It,after ma king this Certificate of Exemption,you
Fshould becomes.),pct to the Worken'Compematlon provblom of the Labor TOTAL:
W Code,you=at forthwith comply with such provislom or this perrrdt shall be
W > deemed revoked. - .? &V
CL IhercbyafCONSTRUCTION LENDING AGENCY SEISMIC FEE
D
flrtn that there is a comtmction lending agency for the perform ELECTRIC FEE a�
Z anes of the workfor which this permit is Issued(Sec,.3097,Civ.C.) TOTAL:
02 lender's Name PLUMBING FEE
LL F Lendar's Addmea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I.AllythatllavercadtAhapplicationandstatethattheaboveieformation
fEI Iseorrect.l agreeto comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. 0. to building commedl.n,and hereby suborder representativnea this
Fcity to enter upon the above-ncnliodsd property for inspection pu rposes. ALTIRORADDTOMECH.
Z
(We)agree to save,Indemnify an d keep harmlem the City of Ce Fortino - Date Receipt#
V agalnstl billtles,jidgments,cosmand expenses which nuymanyway.mme AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
agal a d0tymenosequenc he p/)tart ,colt
PQM /tl AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
1
Sig rco(App canVC.mra r D to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: .
HAZARM S MATERIALS DISCLOSURE
Illthe a FEE. or foto building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)da Data RCCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I leallh and Safety CoSe 32(a)2 HEATING UNIT 100,000 BTU) TOTAL:
❑Yea No
Wllemt banes mous
o building oat eflre use the Bay Area
devices VENTILATION PAN(SINGLE RESID) ISS TE
whichemitair contaminantaasde0ned by the Bay Arca Alr
Quality Management IX+t_ga]y BOILER-COMP(7HI'GR 10Q000 BTU) MAK 13 IJJV
4 Yce yNo r`
Jove read the hazy us matenals requirements under Chapter 6.95 of BOILER-COMP(OVER IW'00)BTU)
the California I Instill&Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT.
resporaibllitytonatifytheocmpantoftherequlrementawhichmustberrct City Of Cupertino
to Issuance Ofaate o¢ ncy.
i
ec !r..t orizeda t
Data
TOTAL ISSUED BY:_ U
OFFICE COPY