20229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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BuildinR Project Identification PERMIT NO.
Building Addmaa: /�O ^/"1
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wnere a o c IIIALUAIH
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f-�(o- CITY OF CUPERTINO-BUILDING DIVISION / -(
C°°trees°: Nan.: Lir.No: APPLICATION / PERMIT
HUILDING-ELFCTMCALnL HING.MECHAMCAL CATEGORY CONTROL M
Arthltees/Engineer. Lk.No:
•'QTY 'ELECTRIC PERMITtr FEE BUILDING PERMIT INFO
FLU
Addre.x
PCRhRTISSUANCE 12,00 ❑ ❑MB MEUH
❑LICENSED CONTRACTOR'S DECLARATION..
IhthSyt.flrmthat lam Bcen3oftheunder pnessaAd of Cssions9(mmmmc- MPWANC6RESIDENTfAL - JOB DESCRIPTION
time.hSection 7000)ofd ciited. (the8uslnnsand Pro(eWoneC°d.,and my
lire..¢Is to full force and died. PANdS &/ E
Lia_ Claes Lk.M r� j 10
(�L -
Date Conlrador '
ARCHITECTS DECLARATION 701-1000 AMPS
�ppLuu aO Zp shall I undersand my plans all be used as public records. OVER IODO AMPS SQ.Fr. RARER f/SQ.Fr.
Fi Licensed Professional SIGNS ELECTRICAL N
<<� ffirm
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISCO 'v
F Ihereby athatI am exempt from the Contractor's License Law for the 0 .
ZR.q following aa.on.(Section 7031.5,Business and Pretensions Code:An d or ]IVB'
FZI"u( cmntywhichnquiresapermittomm"ct,alter,lmptove,demallah,orrepalr TQ`1P'MEIFRORPOLEINSf.
q� 7 a nystmmmpHortolu Wuance,abomryimtheappUnntformuchpermitt- iI. O
t`O file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Q6 C.M d.rb Lice.Law(Cha pter9(mmmendng with Section 7000)of DWI- SWIMMING POOL ELECTRIC
slon 3 of the Business and Professions Code)or that he is,exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE7S5W[7CHES.HXTURFs
sc
<X applicant fora permit subjects the applicant to a civil penalty of not ore than
five hundred dollars(SM,
or my employees with wage as thele sole
f the pNEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPECONSTRUCTION
�n I,as owner o
cont ec.701n,wustoess anddo the rk,Pr endtheionsCdure ion Contractor orofferedLaw
p sale(Sec.apply
to alnow and Professions Code:The or impdola License Law
$$ don nes apply torn owner ofpropertyhiswho
nemplrimproviut ovided thereon,and OCC.GROUP RES.UNITS
who due
mnts amwork Mm.ededoofferedowne.If,ho epr,thebuhatsucr, �O
improvementsareo°t Intended earofcdforsale.If,h er-y ilderwdi.gve TOTA
Improvement lesoW within oneycaw(<ompldbrythe owneabulldcrwlll have
tle�erdan of prevmg that he did nes build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIAOD/ONE APN
LJ L as owner of the property,am exclusively contnding with licensed
contactor tomretrud the project(Sm 70K Bualnessand Professions Code: PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN h VENT (EA)
builds or Improves thereon, and who contracts for such pip)ed - -
s with a FEE SUMMARY
c,6t� Secadons)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE
LI I s exempt under B k P C for this rca...
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
Date � RFC=M
WORKMAN 'OMPETI5ATI0 Da.
RATION rePD('NRF -PER.TRAP SCI{OOL TAX Y N
I by affirm that 1 have a arHflat of c°nsent to self-Insure,ora RECEI NM
artl0oteofWorkers'Compenaatimlvura°m°rnartlfledmpythenof(Sec, GAS EA. OUTLETS 3800,Lab CJ PARK FEE Y_ N
Policy p –
n GAS EA.SYSTEM-OVEftd(EA)
RECEIPT
T q
CmCeYified copy Is furnished. — BUILDING DIV
ISION FEES
❑Certfed copy bfiled with the city Inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EI(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSORM EA 200FT Date RCai t#
Rhb coax.) need no[bo completed If the permit isfor one hundred dollars
($1I comlyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ll not that o the person
i any heworkmanner sores tobecos become
smit isubjec Wued, —
I shall not employ any person In any manner ro u to become subject to the WATER SYSTEM/TREATING
Worlicant ompenaatlon laws o/Callfomis.Date PAID
Z0 NOTICE TO APPLICANT:]!,after making this Certificate of Exemption,you NEW RLSIDENTTAL PLMH, SQ.FT. Date ReCCI t#
should bemm..ubjed to the Workers'Compensation provision of the Labor - TOTAL:
CC W Code,you=at forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILDIN
WG
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafflrm thatthereba mnstmdlon lending agency for the xrform, TOTAL -
ELECTRIC FEE
7 Z ance.fthe workforwhichthbpermt b Issued(Sec.AN7,CIv.q PLUMBING PEE
(� 50
O Uande/.Na
me
LL F Lendae.AddrcssqTY. MECHANICAL PERMIT FEE MECHANICAL PEG
O W Icedlfylhatl haveread/hieappliratbnand stateshattherbovei.lmmatlon
is cormet.I agree so comply with all city and county ordinances and elate laws PERMIT ISSUANCE PEE-PAID:
} S relating to building mmtronion,and hereby authorlu representatives offlab
F 2 city to enter upon the above-martioned property for inspection purposes. ALTERORADDTOMECH.saDate ReCCI
_ (We)agree to give,Indemnify an d keep harmless ep harthe City of Cu pen Ino p
against liabilities,pdgrrnnb,costs and expenam which may In any way... AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL,
against said City In consequenee of the granting of this permit. -
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Appemnt/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or Nture building occupant store or handle haaardous HFATING UNIT(IU 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the Date Receivtit
Health and Safety Cud Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU TOTAL:
❑Ye. No
Will the applicant Cors(uture:wBdug occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous air cont.enn.ms as defined by the Bay Area Air
Quality Management Distnet? BOILER-COMP DHP OR IDO,IXq BTU) pAR^
qYn No CABRi
havenHealthe h
a Coes raterb action 25505,
bundeand 2SS 4. 1 of BOILER-COMP(OVER 100,000 BTU)
the understand
Californiat Health&Sandy Code, of cu ra 75505,have
t and 75534. 1 199J
nndentanlityto fei tui he0 donnot erequine aveatenanLthat bamet NEW RESIDENTIAL N[ECF'I. �,.FI MAY 1
I rnponsiignianeoffa thio ant of the requlremantewhich must be met
pri issuance o(a rtifl of to.
f' r)f rifnar ino
er or authorized agent Data
TOTAL: �/,//p ISSUE _ / � C�
OFFICE COPY