20072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEJthIT NO. 0 O
Building Add mss:
72
wnenul-sine: � A-- e one CI PCUPERTINO-BUILDING DIVISION p
c lode .Name: Lir.Ne: APPLICATION I PERMIT 3 ^� d^ ( O
Arc It cl/ gin Lk.No: BUILDINGFLECTRICALPLUMB(NGMFCHAMCAL CATEGORY CONTROL N�'y
/I F�yt QTY ELECTRIC PERMIT FEE _ BUILDING PERMIT INFOI
Add ems
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that menerprovlfChapter9( n
APPLIANCES
RFSIDENTIAL JOB DESCRIPTION
hSectionofDivsi3ofiheguessand PrrofulonsCndle,and my
Beer. in force and effect. PANELS
LiceneChs Cl.#
��Date C or -�'tA'&��
ARCHITECTShallbeUECGRATION OVERT AMS V�
ts0 7 I understand my plain shall be used u public records. OVER 1000 AMT'S �.Fr.FLOOR AREA SQ,Ff.
O
E d 0 Licensed Professbnal SIGNS ELECTRICAL
d�¢Lu OWNER-BUMDERDECGRATTON SPECIALCIRCUIT/MISC
7�� herebyafBmthat lamexempt from the ContradorsLicenseLA.for the
following recon.(Section 711)15,Business and Professions Code:Any city or
O TEMP.METER OR POLE INST.
pm countywhich requires a permit to construct,alter,improve,demol6h,orrepair
< anystm=mpr rtoits Wuance,ah mquimatheappliantfmsuchpemdtto POWER DEVICES
r V file a signed statement that he us licensed pursuant to the provisions of the
3u' Contractor's License Law(Chapter9(commencing with Section 7fl(10)of Disk
p res SWIMMING IDOL ELECTRIC
F,f5 s the basis he for the
essaIle e d PMeaio.Crisis)n4,violation f exempt therefrom by y VALUA710y^
the basis for the alleged exemption. Any t tolacivi of Sect o mat
re any OUILETSSWI1CIiESFlXTURF5 D D d a UJo
¢O� applicant tura perontsubjectsthe appllcamtoadvll penaltydnat morethan v
$ five hundred dollars($500), NEW RESIDENTIAL RLECTR_SQFP, WFS TYPE CONSTRUCTION�n ❑(,as owner of the property,or my employees wit h wages as their sole
compensation,wllldothe work and the structure Is not Intended or offered for
Osale(Sec.7044,Business and Pmfemloru Code:The Cmdradors License Law
$ does not apply to an owner of property who builds or improves themes,and
o• who does such work himself crthrough his own employces,provided that such OCC.GROUP RFS.UNITS
improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement bsold within one yearofcompletion,the owner-buaderw111 have
ten of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE, FIAODZONE APN
L Wsa owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pre esviom Code;
The Contractor's License Law don net apply to an owner ofproperty who
builds or improves thereon,and who contracts for such p�ojeds with a ALIER-DRAIN&VENT•W BIM
co ctor(a)licensed pursuant to the Conmador'sLicense Law. BACK FLOW PROTECT.D FEE SUMMARY
LJ I am exempt under Sec. B&P C for this mason
DRAINS FLOOR,ROD, ND. SANITARY Y N
Owner Date REGRBPr N
WORK MAN COMPENSATION DECLARATION_ MnwTRAP HOOL TAX Y N
❑I hereby affirm that I have o l rtcone of consent d selfInsure,ora REC 117 B
certiflote of Workers'Compensatlon Ireurance a a artiflM copy thereof(Sec.
33001Ia1,CJ GAS E.A. -1W RIS Elf Y N_
I'ol(ryN CAS G. -0V (EAI RECEIPTN
Com any BUILDING DI VI SION FEES
cc
copy Ll hereby famished. GRGSE/W six ASIRI PLANCHECK FEE
�Sertlfied copy le filed with the city W pection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissedlonneed out be completed lithe permit bforom hundred dollars SEWER-5ANIT -STORM Ek RF. Date Rece1PtIf
($loBleness.) WA w/v ECTR ENERGY FEE Y N
I ceutify that In the performance of the work for which this permit is issued, N—
I shall not employ any person In any manner se as to become subject to the WATER SYSTEM/TR
Workers'Compensation Laws of California. Date PAID
ZZ NOTApplICE NEW RESIDENTIALP B. SQ.FT. Date Recei til
O NOTICE TO APPLICANT:IL after making fish Certificate of Exemption,you
should become subject to the Workers'Compersatlon provisions of the Labor TOTAL: 4o.rV
CCN Code,you must forthwith comply with such proWiem orthts perrrdrshall be
LU > deemed revoked. BUILDING E _ V
W mFE a IherebyafRo CONSTRUCTION LENDING AGENCY SEISMIC FEE . OC"
rm that there le a construction lending agency for the perform. ELECTRIC FEE
Z meeoflhe workforwhich this permit J,;lamed(Sec.W97,CIv.C.) TOTAL: _
02 Lenders Name PLUMBING FEE
LL F Lander.Add rev QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW mer.1.I.dilyth.1 have read,hlsappucaumond mistral theabove hummation
IL Vmrred.legreeto comply with all thyand county ordinances and elate laws PERMITISSUANCE FEES PAID:
} N relating rebuilding construction,and hereby authorlra repreaentativeso(this
(_ Z city to enter upon the above-menBoned property for Inspection purposes. ALMORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,coatsand expenses which may In anywayacerue AIR HANDLING UNIT CI'010,000 CFM) SUBTOTAL'
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies est or furum building occupant atom or ha od to haaardous HEATING UNIT(TO 100,000 BTU) Date Reeei f#
material as dented by the Cupertino Municipal Code,Chapter 9.1Z and the -
Health and Safety C WeLSeytton 75537(a)7 FIFATING UNIT(OVER 100,000 BTU) TOTAL: 10
rlYn . L Nct
_
Rill theappllaut orfuNre building occupant use equipment or devices VFNIILATION FAN(SINGLE RFSID) ISSUANCE DATE
'"I which cont hasardous air contandnants as defined by the Bay Area Air
Qu Pity Maeagemma District? BOILER-COMP(3HPOR100,0(DBTU)
' stn f U9e
have read the huar�us materials requlmments under Chapter 6.95 of BOILER-COMP(OVRIf 700,000 BTU)
theCalJornia Health&Safety Code,Sediotu 75505,25533 and 75534. 1 APR I G i99U
f r' understand that if the building don not arrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Rr.
responsibility to notify the occupant of the requirements which moat be met -
'priortojsSvanre(x�ofaCe�ficate fOsrm,I panty. filly 0f�upet 0
Owns`(-fro audio` '—91st � ` DOe �D IUTAL: ISSl1EDBY. YIC/r ��Q.N'\y�.�.'��N
OFFICE COPY