19892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Praect Identification PERMIT NO. 9892_8 9 2.
Building Address- � ��
A.-o Ar
lir ` Wane:
L��PE7� U,�jfi , 2, CITY OF CUPERTINO-BUILDING DIVISION
— contraanrame: Lk.Na: APPLICATION / PERMIT l�"L
�SAaj&loV BUILDING-ELECTRICAUl'LUMBINC-MECFIAMCAL CATEGORY CONTROL M[`�
Ilect/Engineer. Lk.No: J I
I 'd'
.�A(71C Apar QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I2ci a
Address: PERMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I lumby affirrot)ut l am licensed under provisions of Chapter9(romome- APPLIANCES.RESIDENrIAL JOB DESCRII'1TON
l'ngwith Section7000)of Diviston3ofthelluslnessand PrafesNons Code,and my
iana tela fuV nd ' PANPANES ^
Lkense Clan Lk.#k.N orDate_ Contract /�&�Y ARCHITCTSDECLARATION
-
1Jou
201-1�AM�o
pQ±re�y C2 Iundentand my plamslu0 be used as public records. OVERIOOOAMPS ,�yaarr SQ.FT.FLOOR AREA S/SQ.Ft.
Licensed Prefemtorul SIGNSELECTRICAL S W
fn.4 OWNER-BUILDER DECLARATION SPECLIL CIRCUIT/M
Zp, I herebyaffirm that l am exempt from the Contractor's License Law for the
p Q following Mason.(Section 7031.5,Business and Professions Code:Any city or
KEll countywhichmquimapert twmmtm"ter,impmve,de=16h,orrepalr TEMP.METII ORPOL I S .
any suuetua prior to its leummce,abet requires the applicant for such permit t TOWER CES
a Fite a signed statement that he b licensed pursuant to the provide.of the
3 mt; Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWNIMI POOL RI �
�E Oj doo3ofthelhusine....dPreftealma Code)orthat he as d VAI.UATION
exempt therefroma. ,.ra
/coo,
< the basis for the alleged exemption. Any violation of Section 7031.5 by any f1I ��rY
applicant for a permit oubjectathe applicant too civil penalty of no more than _t OUTLE pI �Sy
° five hundred dollars(;SW).
R� ❑I,as owner of the property,or my employees with wages as t heir sole NEWR D A - STORIESTYPE—CONSTRUCTION
C compensation,will do the work and the structure is not intended or offered for
'S O sale(Sec.7004,Business and Professions Code:The Contractors License law
( 3$ does not apply to an owner of property who Wilds or Improves I hereon,and
CC who dcessuchwork himself orthmugh hisown employees,provided that such OCC.GROIIIa RFS.UNITS
improvements are not Intended ororfered forsale.If,howoveq the building or TO AL: 4
Improvement bsold within ane yearo(complation,the owner-W Ilderwlll have
_ tllg.�urden of proving that he did not build or improve for purpose meals.). QTY. PLUMBING PERMIT -.FEE PEBUD LANE -PN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE 2.dy
The Contactors License Law don not apply let's.owner of property who �ppR-DRAIN k VENT WATER(EA)
Wilde or improves thereon,and who contracts for such poojecta with a
D$(actor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
Cq
L,J I am exempt under Sec. B k P Cfor this reason
OUTSI UP FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date
WORKMAN COMPENSATION DECLARATION RECEIPT M
❑1 hereby affirm that I have• l.urate of consent ro. Insure,ora 2 FIXTURF_rTRAPPFR TRSCHOOL TAX Y N—
artirlatex.Worken'ComperuaHon Wuranre aacertltled ropythenro((Sec. RECEIPT
I #bCGAE .ST -1 INC40 'IEPARK FRE Y— N
P. qJAZ ''l7O' 41 Z C
REC
7
Cmanv GAS F.A.SYSTRM-OVER4(EA) BUILDING DI VISION 171:ES
ertme copy;hereby furnished.
Certified copy b filed with the city inspection division. GREASE/NDUSTRL WASE INTERCEPTOR PLANCHECKFEE
R7•�,�,� I�,
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASETRAP PAID 6� J"Ls'f
COMPENSATION INSURANCE SEWER-SALARY-51011M SFT. Date Recei tN
(hissection need not be completed if the permit b(or one hundred dollars
($1 camlen.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Iartily thato the person
for whkhcopermitle booed, —
I shake not employ any person In any manner n n ro become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDEN'I3AL PLMB. Dale RCtt'1 t#
Z O NOTICE TO APPLICANT:If,after nuking thla Certificate of Exemption,you SQ.Fr.
should beanie subjM to the WorkersCompensation proviatoes of the Labor TOTAL:
Cr N Code,you=at forthwith comply with such provisions orthls pementshall be
9 deemed revoked. - BUILDING •E
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihambyaf0rmthat there b a mnstructten lending agency for the pertornv TOTAL: �s(�� ELECTRIC FEE
Z anceofthe workftr which this permit h ismed(Sm.3097,Civ.C.) - ae.ar/
V O Lander.Name PLUMBING FEE � t Qlp
LLE- Leader.Add re.e QTY. MECHANICAL PERMIT FEE MECHANICAL FEE m
O W Iartilythatl have readthisapplicattonand statethat the above information r aa���•
IL lacnrrcct.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE L�W FEES PAID:
>. W relating to building condructiom,and hereby authoriae representatives of this
I— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date ReCCI IM
— (We)agree to save,Ind comity an d keep hamNem the City of Cu pert Ino P
against liabilities,Pdgments,ms band eipeemi which may in any way amus AIR HANDLING UNIT(TO IEEODO CFM) SUBTOTAL:
ago Wteaid Ci ronaequence the ting of the permit.
3 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ignatvre fApplia.t/ ontractor D e IXFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE
Wllltheapp8ant or future building occupant store at handle huardous ']� HEATING UNIT(TO iolLwo BTU) Q er Date
mutedal as aefinedb the Cupertino Municipal Chapter 9.1 'Recei tp
y p pa p 2 and the
Health and Srtety Co r u t1on 2553i(ap HEATING UNIT(OVER IW,OW eTU) TOTAL:
❑Yes o 1
Will
erothppacamo t t.mins.ammpantuae the Bay Area
devices VLMDLATIONFAN 6INGLE RESID) 121 ISSUANCE DATE
whtcneManagement IrmataM.a.b ae de0ned by the Bay Area Alr
Quality Management QlatysT7 BOILER-COMP PhIPOR1IXI,IXD OTU)
❑Yes o
I have read the hoz ous materials mquiaments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the GII(ornla Health k SafMy de,Sections 25505,25533 a.d 25530.I
understantl teal if the build on notmmently haveatenapq that 4my NLW RESIDGITIAL MECH. SQ.Ff. 4'aaY�b� I
respoolbll notityth pant of the requlrcrtentowhihmusl emel
prior aofaG f to of Ocmpanay.
rl 31990
or uthorize agent to
TOTAL.: `Q(! ISSUED BY:
OFFICE COPY
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I'�f 240 tJ��T- 4 a.? /Cc5D� MP. ¢ `3So�H cu. ,rnu
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