19734 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildfi Pru�vct Identification I PERNRTN
Building Address: /2 _h
051 cSOLY) Rd . (l J V � 9734
am
s e: Phone:
w r /� �/� -2/�D CITY OF CUPERTINO-BUILDING DIVISION .'
ca r d r'eNa �fJj�is/,a_Va: APPLICATION /PERMIT
i4s "r'K� BUfLDING-ELF MCAL-PLUMBING-MECHAMCAL CATEGORY CONTROL#
Archtted/Engineer: Lie.No:
QTY
"''E'UILDING PERMIT INF
Address: If PERMHISSUANCE /p2' ❑
LICENSED CONTRACTOR'S DECLARATION
I herwyaffirmthat l ambcensed under provislonsof Chapter9(commenc APPLIANCESRESIDENTIAL. JOB DESC ON
Ingwlth Sectton7000)of Dlvlsian3ofthe BuslnessandPmfessionsCode,and my
license Is in to orm and efleR. / PANELS
License Cla Lic.ir
DateContractor r 1 - a
ARCHITECTS DECLARATION 01.
�pv 1 N
OO❑Zl understand my plans shall be used as public records. OV 4000 ',.,.-• I SQ.FI.FLOOR ARTA $/SQ.FL.
Licensed Professional --SIGNSE A II t, . 1
�¢6 OWNER-BUILDER DECLARATION _6E
"
Tp thereby aflmtthat lam exempt from the Contractor's License Law for the C /M
OZ following resaon.(Sectlon 71111.5,Business and Professions Code:Any city or
countywhlchrequlresaper ttocontmd,altepimpmve,demolbh,orrepalr
rgCac.: ' anystmdure ptlrnto its lssuarmalsorequircathe applicant for such Permute..--POWERD CE
�V file a signed statement that he Is licensed pursuant to the provisions of the
wi� Cunlradors License Law;(Chapter 9(commencing with Section 7000)of Divi-
SWRI(MlINKADLELECIAC VALUATION
,��0� slon3of the Business and Pro(emlona Code)orthat hebexem]rt[hercfromand
the basis for the alleged exemption. Any violation of Section 7031.5by any O WITC FIXTURES
C applicant for a permit subjectsthe appllcantto a civil penalty of not racZhan
c, five hundred dollars(5500). R D A ELFOTR SQ
j ❑I,as owner of the property,or my employees with wages as their sole .FT.
STOIIFS TYPE CONSTRUCTION
compensation,will dolhe work andthestrudure bnotintended or offeredfor
Osa1e(Sec.7044,Business and Professions Code:The Contradofs Licease Law
(7, $ donnotapplyw an owner ofproperty who bulidsor improvestherame,and
a who doessuchworkhimselforthrough hisownemployeas,provided thatsuch OCC.GROUP RES.UNITS
Improvements are not intended oroffered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearofcomplMbn,the owner-builderwlll have
t"rden of proving that he did not build or Improve for purpose of sale.). QTY., { PLUMBIN G PEItMiT r. ''}`EE' FLOOD TONE APN
jJ 4 as owner of the property,am exclusively contracting with licensed PFRMI'I'ISSUANCE
to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
builds or Improves thereon,and who contracts for - -
for such ptoje
s with a „FEE SUMMARY
on,tLt.;�actor(s)licensed pursuant to the Cootradorb License Law, BACK pfAW PROTECT.DEVICE
LJ I am exempt under Sea B k P C for this reason
-
OUTSIDE
Owner Date DRAINS-FLOOR N_
ROOF,AREA,COND. SANITARY Y_ �.
- RECEBPf#
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y_ N
[:]1fO
1 hereby arm that I have a certificate of consent to cel(-InsureFIXTURES-,or RECEIPT#
certificate ofWor/keni Courp�ecoart�lon IImoraance or
a certified copythereof(See. GASFA.SYSTEM-1 INCAOUTLETS PARK FEE � Y N-
P.li38M(pis C.) V L4E"'or,/P:3 (+`3.� - RECEIPT#
Com anCG n A'/ GAS.EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certmm copy is hirebyhthecity
famished. GREASEANDUSTRL WA NTFRCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspedlon division.
CERTIFICATE OF EXEM f10N FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWS&SAMTAR TORM F.A.200Ff. Date Recel t#
(This section need not be completed If the permit is for one hundred dollars
($]OD)oify that
WATER FLEA W/VENT/ELECTR ENERGYFEE Y N
Ill not that In the person
an th courser
sa as to become,h this permitbjcc blued, —
I shall not employ any person In any manner ao u to become subject to the TEM/TREATING
Workers Compensation Laws of California.Data. WATER PAID -
O Z Applicant Date -
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you NEW DFM]AL PLMB.__sQjr. Rete{ t#
Fshould become subject to the Workere'Compeosatlon provisions ofthe Labor TOTAL:
N Code,you must forthwith comply with such provisions orthb permit shall be
> deemed revoked. - -BUILDING FEE.
W
C CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Iherebyaffirm thatthereisa com uction lending agency for the perform ELECTRIC FEE ��yy
M Z anceofthework forwhtchthispermlt is Issued(Sec.3097,Civ.C.) TOTAL -p
V O Lender's Name PLUMBING FEE
LL F Lender's Address QTY. IvIL�HANICAL:PE6MIT FEEL . MECHANICAL FEE p0
O W IceAffythatl havereadthb applivationand statethattheabove Infamatlon " )
tl bcooact.Iagowto complywithall dlyand county ordhotrmsool nate laws PERMIT ISSUANCE /�•VV FEES PAID:
} W relating to building construction,and hereby authorize reprnentatives ofthis -
(— Z city to enter upon the above-mentioned property for tmpmion purposes. ALTERORADDTOMECH. Date Recei t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,udgments,was and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,Wo CFM)p.lSUBTOTAL;
against al tyinconsequence ofthe granting of this permit./�/�t7
.Xa tA� 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa( Applicant/Covtractor f Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IM,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the - (-
Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,00D BTU) TOTAL: 5��
❑ yesM No
Will the applicant or future building occupant use equipment or devices VENDLATION FAN(SINGLE RESID). jS t(aTf(•g DA'Z'E
which emit hazardous air contaminants as defined by the Bay Arca Air - ;O'.Ps'�R1,r,ZV$
silty Management District? BOILER-COMPOHPOR 100,000 BTU)
I I Yca [j No `
have read leech&Safety
mater,Se req x25505,2under 5533 aChapter.1 of ROILGR-COMP(OV172100,000 8TU) Y ^ sy p
.the California Health br building
Code,Sections25505,h ve ate tenant,that
f9 1�
understand that lfthe b the occupant
note osquiyments tenant teat itIs mymut NEW RESIDENTIAL MECA. TQ.I"T.
responsibilityriortIssuance
c coli(ytheocte of c panequircments which most be met /It}ta wf
prior to Lssuance of Certificate o(Occvpanry. � SY.11ab! at
Owner or authorized agent Date - r Ifs
TOTAL: ISSUED BY: ^��w'���a.
OFFICE COPY