20197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERNE[I'NO.
Building Add...: ' - - 20197 O a� n�'J •.
OS S U G I �9J I
era ams: one:
�;a III wo IU 411 1 hy9 CITY OF CUPERTINCL BUILDING DIVISION p
muract.e.Name: �� Lie.No: APPLICATION / PERMIT
O BUILDINGELECTMCA PLUMBINGMEGHAMCAL CATEGORY CONTROL#
Architect/ linter. Lic. o:
QiY -"• k t#ELECTRICPERMlii it "jti,FCE-YHr "1' 'E„BUILDING�Pf RMITINFO
Address: PETWTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am Bcmm under provisions ofChapler 9(commenc APPLIANCESRESTDENML ]OB DESCRIPTION
Ingwlth Sedton70gD)of DlAsion3ofthe Businemand PmfeulonsCode,and my
license is In full(,,e..d dim, EL
30 / PANS '.
Lkcnsc .
lass
DateCLanIctnctor .0 ARCHITF.CPSD CLARATION 201-1000AMPS
quq�aa 0OZ0understand my plans shall be used as publierec.rds. OVER IOW AMPS' - SQ.FI',FLOORAREA /SQ.Fr.
}az`j Licensed Pmf.mr.I - SIGNS ELECTRICAL
dfn¢LkS' - .OWNER-BUILDER DECLARATION' S7+-CIAL CULT/M ”
I hereby afnrm that am exempt from the Contractor's License Law for the -
Ocmntynwhichrequimsaopn7mtto roBunssitnmeacte,aanitderPimplm v,de=elhh;oyrctretypaoirr4
Taai any structurepd.rtolts Ls...e,also imatheapplimntforsuchpermltto WER D,
�4 c.U file a signed statement that he V IlcensM pursuant to the ProvL,iom Of the
Owl-t Contractors License Law(Chapter 9(commencing with Senion70110)afDivl-
3 .J7 cion 3 ofthe Business and Professions Code)orthat he is eaempttherefromantl A"NCrj1LELKyC VALUATIO
X'
the basis for the alleged exemption. Any vlolatloo of Se tion 70315 by any O E 7C ES 610 .
.
65 applicant for a permitsubject,theapphcant too civil penalty of not more than
five hundred dollars hepr. - FNITAI R FT. S RIES TYPECONSTRUCTION
mI,as owner of the property,or my employees with wage-as their woe
C comp.coatiKfloldothend Pro ssiomtmctvrche is Contractorot or offered La r
sale(Sec.not apply
to an ow and Professions Code:The Contractors License law
w1b.d...rhmanownerofpropeh hi.om who emilds ployees,
provided
thatsuch and OCC.GROUP RES.UNITS
0. whodoemnts am kMmeededoroffered wghhieowne.If,ho ea,p ,the
dilding or
improvements lntend6eyearfcomplellon,the.ILhowevegilder illhave TOTAL: -
imilurda ofproldwithat he did nrWild rImpovefopurpose of sle.). S, r n,,, „ .it, .e
tlinjmrdeno(pmvingthat hedid not build orlmpmve(or purposeafsaleJ. QTY,t , 6'6 PLUMBING PERMIT }`',i• 7• rrFEE FLOOD ZONE APN
LJ 1,as owner of the property,am exclusively on.... ng with licensed PERMITISSUANCE '
contractors to romtruct the project(Sec.70K Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon, and who concocts for such pRojects with a ALTER-DRAIN&VENT-WATER(EM .i
,afiRd((aaeor(a)licensed pursuant to the Contractors License Law. - '••.1 1 FEE SUMMARYi+'
L)I am exempt under Sea B&P.C for this mason BACK FLOW PROTECT.DEVICE OUTSI OF FEES
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y N
Owner Date - - RFLERPr#�
sq
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOL TAX, Y xN
Lpl hereby affirm that I have a lmnnte of consent to se141nsure,ora RECEIPT#
Alflcate of Workena'Compematlonlmurance.racertifled ropy therrof(Se<. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Polis[abCJ I — eup'Ia�1'-40 - — RECEIPT#
Policy# _-��
Com any a ALA.�bLs' CAS G.SYSTEM-OVER#(G) •�. BUILIIINGDIVISiONITES
Cerdliedcopy is herebyth theh d. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHEGIC FEE -
CertBied copy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
INSURANCE
COMPENSATIONCE SEWER-SANITARY-STORM EA.200FT. Date Recei tN
f• (fhlssection need lot be completedtithe permit NSURAN forom hundred dollars
(8100)or less.) - WATER HEATER W/VENT/ELILTR ENERGY FEE Y N -
I certify that in the perfomanceaf the work forwhich this permit la Issued,
I shall not employ any person In any manner so aam become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date - PAID
z z Applicant NEW RESIDENTIAL PLMB. SQFr. Date . Recei N!
Z O NOTICE co APPLICANT.If,ager ra'Compensation
om a Ceronicateof Exemptlon,you -
F Code,you=at
forth ith co ply with
Comprovisinprovbis permit s Lab or TOTAL: -
LU N deemed remlood. with comply with wch provisions or this permli shall be B NG ••E 'V
deemed revokN.
W — CONSTRUCTIONLENDINGAGENCY SEISMICFEE .. as
d G I hereby affirm that there is a construction lending agency forthe perform- ELECTRIC FEE
7 0 anceoftheworkforwhichthbp.rmltisissued(Sec.3097,CIv.C.) s TOTAL:
V._ Lender:Name t. - PLUMBING FEE
ly,F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O O Icertifythat l have read thisapp8cationand state that theabove information
1 brormct.Iagrceto comply with all dtyand rountyoroinances andatatelawe PERMIT ISSUANCE FEES PAID:
�. relating to building comtmctlon,and hereby authorize representatives ufthis
(— Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH. Date RL'CeI Ill
— (We)agree to save,Indemnify an d lamp,harmless the City of Cupertino P
galmt liabilities,judgments,mate and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
at sold City In granting.(thlspe It. -ZAIR HANDLING UNIT 1Q0a0 CTM) CONSTRUCTION TAX�-FD CONSTRUCTION TAX PAID:
Signature a(App we- Date EXHAUST HOOD(W/DUCT)
AZA
FOCUS MATERIALS DISCLOSURE .
Will the applicant or future building occupant smrc or handle haaardous HEATING UNIT(TO 100,000 BTU) Date Recei IN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)7 .. HEATING UNIT(OVER 100,000 BTU) -
r] Yes No TOTAL,
- , •
Will the applicant or(uture building oavpam use equipment or devices TI
VENLATION FAN(S7NGLE RESID)
which emit hazamous air contaminants as defined by the Bay Area Air -
QualltyManagementDistrict? BOILER-COMP DHP OR 1(10,000 BTU)
:E?Y" �N. ,rt'r"ii -N vrl iLlallJ
haverctdth.Ith&�us rmteri Sldi.WrementsunderChapter, I of BOILEFCCOMP(OVIX1011,000BN)
theerstand thatlithebSafetyCode,not currently
A tend,that 1
understand thatn notify
the occupant
of t the
ngntsw which
that ltkmy, NEW RESIDENTIAL MECH. SQ.h r. City of CU[IEIirto
responsibilityortsuance fa Cere.cxvpantccupa rcquircm.ntswhlcF must be and Y1 1l
prior to issuance ofa Certificate of Occupancy.
Owner or authorized agent Date M1
OTAG ISSUEDBY:A
OFFICE COPY