19672 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PrWeot Identification PERMH NO.
Building Add �I /� r�J n
Svtf�ert_L+4 1 , I a96I G
ners ants: Phone.
F14ULI+�IJ2(✓ CITY OF CUPERTINO-BUILDING DIVISION _•1 C� h'
G°3lraa°�:•'"•ne: NN �! Lic."e: APPLICATION / PERMIT
d1 n`•i macre /,/a'� 'WI 7 l�� BLIILDINC—ME UCAL PLUMBING MECHANICAL CATEGORY CONTROL N
Architect/Engineer. - Lie.No:
on d'ELECTRIC ",d BUILDING PERMITINFO'
' '% FEE,.'
Address PERMETI%UANCE ❑ ❑ ❑ `
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmtlat lam licensed under provisions o(Chapter9(commose APPLIANCLSRESIDENDAL _ JOB DFSCRD'HON
Ingwllh Section 7000)of Division 3 ofthe Businessand Profession.Cods,and my -
Ikense Is In full f and a fret - PANES
Limns. Lic.# u - I •
'Datc5i Bill
UP TO 700AhMS `^#�'/r17
ARCHITECTS DECLARATION 2014000AMP5
0 2 I understand my plain shall be used u public records, OVER 1 W0 AM
OO SQ.FT.FLOOR AREA S/SQ.FT.
q�
Lirensed ProfeniovlSIGNSELECTRI'A
Eco OWNER-BUILDER IDECLARATION,
Ihemmm
hereby exempt from the Contractor's License UI TSC License Law forth. .,
q following reason.(Section 70315,Business and professions Code:Any city or
K ty countywhkhrequlresaper ttomrntmdalter,impmvgdemlbh,ormpair T�r'M % '
q �7 asystructum priorto lb bwance,also requi nathe applicant for such permit to �R DGVI
L5 O file a signed statement that he is licensed pursuant to the provisions of the
(Gjl� Contractor'sLlcense Low(Chapter9(mrruretlM
nngwlthSeon7000)OMNI-
OS don3ofthe Budne.and Professions CodOmthd hebexempttherefromand NG, LE'E VALUATION -
the basis for the alleged exemption. Any violation of Section 7131.5 by any O •TS. TC
applicant fora permltmbjed.theappllcanttoadvllpevaltyofna morethan (v J
five hundred dollars($500).
�n ❑7,as owner of the properly,or my employees with surges as their sole- NEW R EEC SQ.FI'. STORIES TYPE CONSTRUCTION
compensation,wI ldo the work and thestructure is not Intended or offered for
0 sale(Sac.7044,Business and Professions Code:The Contractor's Limrue Law
3,$ does not apply to an owner of property who builds or Improves thereon,and - OCC.GROUP RFS.UNITS
whodoessuchworkhimadiforthrough hisownemployees,provided that such ,
improvements are nor Intended proffered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcomplellmi,the owner-bullderwIII have .,
,'+'
t rden of proving that he dldnext build or Improve for purpose of sale.).
QTy; .;. :'pLUIVIBING PERMIT.',, � - au,'FBE''"
�L as owner of the property,am exclusively contracting with licensed FTAODzoNE nrN
contractors to construct thl,project(Sec.7044,Business and Professions Code: PFRMITISSIIANCE .
The Contractor.Licinse law does not apply to an owner of propertywho ALTER-DRAIN&VENT-WATER(EA)
Wild, or improv.thereon,and who contracts for such plojeds with a 1,
ctor(.)licensed pursuant to the Coutfactor's License Law. ,!y `'FEE SUMMARY
�gUlf+ BACK FLOW PROTECT.DEVICE
L�I am exempt under sec. B&r c for.hiss maven
Owner Data
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N- _
RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX - Y_ N
❑I hereby affirm that I have on Insurance
of consent m opytnwre,or - RECENT#
38 1B.teo(Wprken'Compenutlon lruuranm oramrtifled copy thereof(Sm. GAS FA.SYSTFM-1 INC.4 OUTLETS
IfLabSI - ['ARK[FR Y N _
Poll It. 7.b�77(x CAS EA.5YSTEMAVFR4tTil) - RECEIVE .
Com anv r�/JPL•,m2� YI P - - BUILDING DIVISION FENS
�2eki cony is hereby.f mbhed. '
❑Certified copy is filed with the city importion division. CREASE/INDUSERL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RNP PAID
COMPENSATION INSURANCE
(ThissecUon need not bec°mpleled lithe permit Liforonehundred dollars SEWER-SAMTARV-
STORM EA.2001T. Date Receipt#
(fl O3)orless3. WATER I IrATERV.,/VENT/E.FLTR ENERGY FEE Y N
[certify that in employ
an person in any he manner
ad as tobeco permit b Ito ed,the _
I shall not empensany penton In any manner at u to become subject to the WATER SYSTGt/TREATING .. .,
_ Workers Compensatlonlawsof California. Date . PAID '
'Q Z Applicant - NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z O
NOTICE TO APPLICANT:If,after making thb Certificate of Gemption,you
N 'should become subjad to the Worken'Compensation provfhms or the Labor TOTAL:
LD Code,you mu.tfonhwith mply Mth.uchpmWiamortnbpemtshaBbe
W:> deemed revoked. BUILDING FEE 7- 0
M.3
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that theis a comudlon lending agency for(he perfor n ELECTRIC FEE
Z re tt
ante of the work for which this permit is Berard(Sec.3097,Civ.Q TOTAL: _
O O Lcndcr.Ne me PLUMBING FEE
LL !- Lander.Address Q'rv. 'MECHANICAUPERMIT', MECHANICAL FEB
OW Icartifythatl have read this application rtatethattheabovelnf.rmmlon -
S is corned.Iagreeto comply with all city and county ordinances and gate[am PERMIT ISSUANCE FEES PAID:
} relating to building comtmctlon,and hereby authorize representatives of this
F 2 city to enter upon the abovomentionei property for impnetion purpose.. ALTERORADDTOMECH. Dale ReCCI t#
. (We)agree to save,indemnify and keep harmless the City of Cupertino p -
V aga'ln'th.billtl�f pfigments'
costal x hichmaylnanywayaceme A1REIANDLINGUNTE(TO10,000CEND SUBTOTAL: d- -
ag,�/'lIr,"fG��jt�Y/-a.idzC�{H'mco P�ea/u5/+�eo he gr Ongo his permit...IAIR HAND LING UNIT(OVER 10,60CFM) CONSTRUCTION TAX
IgwluTe of AppB.nt/Cont dor Die EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applead or future building occupant store of handle hazardous HEATING UNIT(T0100,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Ileelth and Safety Coda Se 255324)7 HEATING UNIT(OVER 100,000 BTU) TOTAL -
❑Y. LSNN�o
Wllltheapplirant or fuW mlyuildingo pantumequlpmentordevims VENTILATION FAN(SINGLE RESID) ISSUANCEDATE
which emit hazardous dr contaminants..defined by the Bay Area At, R—A I®I '
Quality Management Distil BOILER-COMP 0 I.
11P OR 100,0W RT
1Yes ' t
4have real the boos au a materials requlnenents under Chapter 6.95 of BOILER-CO\JP(OVER 100,000 BTU) 1990
the California CalifoHealth&Safety Code,Sections 25505,25533 and 25534. I 6. f+ V. 7J V
understand that lithe building does not mrmntly have a tenant,that it is my NEW RESIDENTIAL MECH, , SQ,IT. -
responsibility to notify the occupant of the requirements which must be oat
prior to issuance of a Certificate ofOmrpancy. Cliy (1fi P�I�B.1'f111A,
Owner orauthoriudagent Date - 4 ^K�IV41
". '.TOTAL: ISSUED BY�' �• � .
OFFICE COPY