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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification
9u11d1nj,Addmea:
to�o�
PEWATNO.
^ Y'� lelltiG) 0
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Phone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
Cana ryq: �e:' 1-� 1CR Lie N :
W-'
BUILDING-ELECTWCAL-PLUMBINGMECIiAMCAL
CATEGORY
Cp p O
Archltett/Engineer. Lie No:
QTY ELECFRICPERMIT FEE`
BUILDING PERMIT INFO
Address:
1 PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby a((Irmtlutlam licensed underprovWone of Chapter9(commmc
Ingwlth5ection7000)ot Div1tlan301the Bn
uslnaand ProfeWonsCode, and my
lienIs In full force and died.
Items.
Llom.Clan Lle.1' 66
Date Contmdor_`f
APPLIANCESRESIDENfIAL
OB DPSC HON
�—'
PANELS
ARCHITECTS DECLARATION_201-10DOAMPS
IundemtandmyplamahaRbeuwdupubbcrecmde.
Licensed Pro(esahmal
OVER
SQ.Fr. FLOOR AREA
111
^S//SSQ'FT.
E ECTRIAl,
SPECIALCItCUI
OWNER -BUILDER DECLARATION
I herebyaffivm that I am exempt fromthe Contractor¢ Licens. law lm tis
following reason. (Section 70315, Business and Profembna Code: Any city or
county which requiem a permit t,comtuct, alter, improve, demolish, or repair
any structure prior to its Issuance, also require the applicant for such permit to
fill a signed statement that he is licensed pursuant to the provisions of the
•)41p ME[ERO LE INET.
ppWgg CES c)
1
hg NC POOL ELECTRIC
W&fVALUATION
RIET&SWITCHE&FIXTURES
Contractors License Law (Chapter 9(mmmencing with Section 7000)of CIA.
Bion 3 ofthe Bushes. and Professions Code)or that heIs exempt therefromand
the basis forthe alleged exemption. Any violation of Stolon 70315 by any
applicant (ora permit mbjettsthe applicant io a dvil penalty of nat morethan
16 3 T76
NEW RESIDENTIAL ELECTR SQFT.
five hundred dollars($SM. I
❑ I, as owner of the property, or my employees with wages as their sole
campensation,willdothe work, andthe sbuc urn is not intended or offered for
STORIES TYPE CONSTRUCTION
sale (Sec. 7064, Business and Professions Code: The Contractors License Law
does whodot apply rkhian Morphproperty who
nempIWi ,pv idh ton,and
whodceaents am khimsededorough hhowale.If oweveevidedthatsuch
Improvements are not intended orotfered tonal¢. ((however, thebullding or
improvement haoldwithinoneyearofcompldiogtheowner-buRderwlll have
TpER
I
the burden of proving that he did not Wild or improve for purpose of sale.).
M I, as owner of the property, am exclusively contracting with licensed
comrsams to construct the project (Sm. 7054. Business and Professions Code:
QTY, PLUMBING PERMIT MA
APN ,
PERMIT ISSUANCE 1
L
the Conlvdors License Law does not apply to an owner of property who
builds or Improves theme , and who contracts for such p�rjeds with a
on LttTIado(a) licensed pursuant to the Contractors Lkens. Law.
LI1 am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT -WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND,
SANITARY Y N
RECEIPT Y
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have • cartHlete of consent to self -Inure, ora
certificate -(Walken' Compensation Insurance ora enifkd ropy thereof (See.
3800, Lab C.)
Policy Y
p)1(•NgES PER TRAP
SCHOOL TAX Y_ N_
RFL NY
CAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT Y
GAS F.A.SYSTEM-0VER d (EA)
Caempany
BUILDING DIVISION FEES
I ICertlRed ropy is hercbyth thi city
L�Ji Certified copy is (lied with too city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
��
PAID
GREASE TRAP
COMPENSATION INSURANCE
Qhisaedlonneedndbecompletedifthepev th(caromhundreddollars
SEW FR SANITARY SHAM EA 2001717.3tYK
�1/os,Ga�
Recei tN
ENERGY FEE Y N
($100)mlees.)]yA.�IIFA,1.�ty/VFN'T/EI.FG7.B
I enifythat In the performance of thework forwhich this permit is hued,
I shall not employ any person In any manner m as to become subject to the
Workem'Compenextlonlawsof Califomla. Date
WATER SYSTEM/TREATING
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers'Comperoatlon provisions of the labor
Date Recel tic
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL
BUILDING
Code, you =at forthwith comply with such provialoro or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebya((Irm that there is a corotudlon lendingagemylartheperform-
ance of the work for which this permit h hued (Sec. 3097, Civ. C.)
lander'. Name
Lenders Address
Imnlfythatll vemadthbapplkatbmndoatethattheabove mforrratlan
Is cormd.I.gme to complywithall city and countyordinanes and nate laws
L
ELECI'RICFEE L
PLUMBING FEE --�
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEB
�.
, PERMIT
FEES PAID:
misting to building construe,lon, and hereby, authorize representatives o(thh
city to enter upon the above-mentioned property, for Wpecil-n purpose.
(We) agree to save, indemnify an d keep harmless the City.( Cupertino
agalnstllabllltks, jrdgmenh, cohsand expenses which may In anyway accrue
ALTERORADDTOMECII.
Date Recei tN
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
agaipst Spjd City m ermof the granting alibis permit
AIR HANDWNG UNIT(OVER iO,fDOCFM)
CONSTRUCTION TAX
Signature of Applicant/Contra Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDO MATERIALS DISCLOSURE
HEATING UNIT (TO 100,01)(1 BTU)
Will the applicant or future building occupant store or handle hazardoua
material as defined by the Cupertino Municipal Code, Chapter9.17, and the
Ilealthand SafetyCode Be ion75537(a)7
F7Yes Idl'.I°
Date RCcel tic
O L.
-
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE BESIDE
ISSUANCE DATE
Will the applicant re building occupant use equipment ordevices
which coot harsedoue air eontandronb as defined by the Bay Area Air
Quality Management Qutr ?
Yee o
have read the haz o materials requirements under Chapter 6.95 of
xs
BOILER -COMP 0HPOR 100,000 BTU)
BOILER-COMP(OVER100,000 BTU)
the California Health & Safety Code, Sections 75505, 25533 and 75534. I
understand that lithe building does not currently have a tenant, that it is my
responsibility to notify the occupant of the mquirements which must be met
YHH7pll�/l7Rtl 1992
MAR
NEWRIESIDEMTALMECH. SQFf
��e
prior uancc ora EtatParry.
e
Cllr ur IY4
ISSUED BY:
ner or authoriasd agent Data
TOT
OFFICE COPY