20672 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFdiMIrNO.
Building Address: 14? O.
a$-7-.F 0 20672
wne s ame: _ one: -
q� CITY OF CUPERTINO-BUILDING DIVISION
°"Fador'sName: LIc,No APPLICATION I PERMIT P-a4-�i40
909 6 BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY _ CONTROL If
AmMud/Engtheen Lk.No: -
`' t. ,BU¢DINGYERMIT INFO.
R!'?"' :ECECTRIgPERhI1T,' -' 'FEE
Address:
. PERMITISSUANCR ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene, APPLIANCES-RESIDENTIAL JOB DESCRBT]ON
Ingwlth5 dion70W)of Dlvlslon3ofthe Businessand PmfessionsCode,and my
licenselsinful o e ncleffed. a.....��� PANELS
Llcen Claw= Lic.p eJJ`r -
Date G°nlyddOr C
ARCHITECTS ECLARATION 201-1000"P$
M00O I understand my plans skull be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
d 6 Licensed Professional SIGNSELEC CAL
�6� ffiOWNER-BUILDER DECLARATION C
p„ I hdebyaren t0h' l am exempt from the Contractor's License Law for the SPECIAL CBiMISC
Oz t. following reason.(Section 7(01.5,Business and Professions Code:Any city or gyp.M O E I ST
pz county which requires a permit toconstrud,alter,improve,demolish,or repair
q' any strodure prior to itsIssuance,also requires the applicant for such permit to pOWERD
f-5 fie a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvi-
�0a slon 3 of the Business and Professions Code)or that he is exempt therefromand SWIMMI LELEC VALUATION
S°•..11 the basis for the alleged exemption. Any violation of Section 7031.5 by any OO
G applicant for.permit subjeatstheappllcanitoacivil penalty ofnot room than �TC ES
Q five hundred dollars($500.
❑L as owner of the property, 1 es as their TSTO sole EST L TR SQ. ' TYPE CONSTRUCTION
�n k,
compensation,velli Bothe work and or my employees with wages
structureoe:Th not Intended or icome L for
O sale(Sec.7044,Business and Profesaloru Code:The Contractor's Llrewe law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP- .RES.uNrrS
who doessuch work himself orthrough hismen employees,provided that such
improvements are not intended oroffered for sale.If,however,the building or TOTAL:
improvemenHesoidwithinoneyearofcomp:eti. ,the owner-builcidwlll have
lla.Lurden of proving that be dm not bund or improve for purpose ofsale.). . 'PLU�'IBiNGPERMIT
nt ::FE) F]mDZANE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntadore to con tract the penyd(Sec.7044,Business and Professions Code:The Contractors License Law does nd apply to an owner of property who A47II2DRAIN&VENTWATER(EA)
Wilds or Improve,thereon,and who contracts - -for such jeojede with a .
cgp([ado10)It...d pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
DRAINS.FLOOR ROOF,AREA,COND.
SANITARY Y— N
Owner Date RECEIPT It
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y— N—
certificate
hereby affirm that I have a certificate of consent to�self4reure,or a RECEIPT certificate ofWorker,'Compensation Insurance ora certified copy thereof(Sec: GAS EA. INCA 3800,Lab C.) PARK FEE- Y N
Pollryp RECEIPT p
GAS EA.SYSTEM-OVER4(FA)
Com any Q (;� p�mrlL BUILDING DIVISION FE ES
�Ccrtuie copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTORPLANC14ECK FEE
CertBied copy V M filed with[ city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT.
Qhissectlon need no[otMbe completed If the permit V forme hundred dollars($100)o,less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certlfythat in the performance of the work forwhich this permit is leaded, —
Ishall am employ any person In any manner so as to Weems subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
z Z Applicant - -
Z Q NOTICE TO APPLICANT;If,after making thin Certificate of Exemption,you NEWNTI
RESIDEALPLMB. SQFI. Date Recei t#
Fshould become subject to the Workers'Comperealon provisions of the Labor - TOTAL-
!2 Code,you=atforthwith comply with such provisions orthis permit shall be
> deemed revoked. _ BUILDING FEE x
'1 G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm
that there Is a construction lending agency for the perform- ELECTRIC FEE
Z once of the work for which this permit is issued(Sec.3092,CIv.C,) TOTAL
V Q Lenders Name PLUMBING FEE
IL Lenders Address Q17. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have readthls applicatlonand somthattheaboveinformeBon
Iscorrect.lagreetocomplywlthalldtyandcountyordlnancesand Aatelawe PERMITISSUANCE FEES PAID:
} 1 relating to building contraction,and hereby authorize representatives of this
% city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Coped Ino Date Receipt#
V against llabllltlee,pdgmenb,ccmtsand expen which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Z I
sd Cityin cnn Q
ohe gran f this permit.
.{a �/I p�7 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
51 nature of Applicant/Cdntrador_ CDate 7 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future bulldingoavpant amre or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ' Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cod Ion 25532(a)1 HEATING UNIT(OVER 100,000 BTN TOTAL:
❑Yes o.
Willtheappllcant ACbullding occupant useequipment ordevids VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D' d7 BOILER-COMP(31E+OR IM,00I BTU)
4Yes No
have read the hoz ods materials mqulrements under Chapter 6.95 of BOILER-COMP(OV02100,0008N)
the California Health Safety Code,Sect1on75505,25533and25534.1 (� 'jl,,a ria 980
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responibllitymnotifytheoccoparldloe cements which must be met
prior "issua ce of a�rtlfl pa QV rad/a,rp"m
t Lx---5 lflV YYIswA
Owner or authorized agent / Data
TOTAL: ,ISSUED BY:
OFFICE COPY