19389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPro'en Identification PERMIT NO.
RulldinAddu:
10/�3 1U. ��� , 19389
1
nere - Phone: p
/✓/Zt ✓ ,--, /vMES CITY OF CUPERTTN0.6UILDINGDIVISION / 2 /tO
Corbactor'f Nam: Lic.No: APPLICATION / PERMIT �O 7
dm BUILDING-IlMn ICAI MP HINGMECHAMCAL CATEGORY CONTROL If
Architect/Engineer. c' ' Lie. I
('/'/t����a��� �y ,�/�{� NO QTY ELECTRICPERM FEE BUILDING PERMIT INFO
Address: sn/�J l.H4#1 r[...� PERMITISSUANCE • ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflon that l am licensed under pmvWonsof Chapter9(comment. APPLIANCESRE.SIDENTIAL IrIv JOB DFSCRI[MON
ingwith SecttonMW)of Division3 ofthe Busimasand ProfessionsCode,and my
Ilrense is 1,f Il and dfed. PANELS
UPT
LI¢nseCan Lit.N � llNNov P i'aNw
Date Comrador f/V pt]1100
ARCHITECTS DECLARATION OVERI000 SQ.Fr.FLOOR AREA S/SQ.Fr.
q�q�uu ANPS
O[7O I uMersland my plans shag be used as public rtaoNc
t Z Licensed Professional SIGNSELEC L
<<�Q OWNER-BUILDER DECLARATION SPECIALNT/M
f., J Ihereby affirm m
thatI am exempt frothe Contractors License law for the
ZO F Q following reason.(Section 7(1)1.5,Business and Professions Code:Any A
E W cmntywhichmquimsaperMtlocor tmd,alteglmprov demollsh,ortyPat, R POLE
'y or or TER
KEMP
anystrudure prorto its Issuance,alsorequimslheapptimnt for such permit to DEVI
E r F file a signed statement that he Is licensed pursuant to the provisof the
Contractors License Law(Chapter 9(commenWgwith Section 711W)o(Divl- NC L ( VALUATION
O ulon3 oflheBusines,and Profemiom Code)orthat hebexempttherefromand
F~ Sn S the bash for the alleged exemption. Any violation of Section 7m15 by any OUTLETSSWI XTUR /Y
os applicant ora permit sub)edstheapplicanttoa dvil pemltyofnct more than
T. Ove hundred dollars(S500). NEWRESIDEN]IAL ECTR SQFI. STORIES TYPE CONSTRUCTION
j.. n I,as owner of the property,or my employees with wages as their sole
compensation,will dothe work and the structure is not intended or offered for
psale(Sec.7044,Business and Professions Code:The Contractor's Limme Law
,$ does not apply to an owner of property who Wilds or improves thereon and OCC.GROUP RES.UNITS
F$^ whodmssuchworkMrnselforlhrough hisoweemployeco,provided that such
Improvements are not Intended oroffered formic.If,however,thebullding or TOTAL:
Improvement issold within one yearofcompletion,the owner-builder will have
t"rden of proving that he did not baud or improve for Purpose of ale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract.to construct the project(Sec 7044 Businessand Professions Code:
The Coatndor's Licence Law done not apply to an owner of property who
Wilde or Improve,thereon, and who contracts for such poujede with a ALTER-DRAIN&VENT-WATER(EA)
c aen'(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
IJ 1 am exempt under Sec. B&P C for this rea BAIX FLOW PROTECT.DEVICE
FEES
son DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Doe RECE1I T N
i. WORKMAN COMPENSATION DECLARATION }TX'IVRFS PER TRAP SCHOOL TAX Y_ N_
1 hereby affbm ce
that I have a rtiOcete of consent to sal(-Insure,ora RECEIPT N
c elflcateof Workers Compensationimumnmoramdi(ie mpythee f(Sec. GAS EA.SYSTEM-1 ING<OUTLETS PARK FEE Y N
3500,Lab G) —
RECEIPT N
Policy N ny
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISI ON FEES
Cg a _
)fiCedl(Ieci copy is hereby famished. GREASE/INDUSTRL WASTE IMfEl2CEPTOR PLANCHECK FEE UsCertified copy Is filed with the city Inspection division. 13
CERTIFICATEOFD(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Fr Date Reeei t#
(Thissection need not W completed if the permit h foram hundred dollars
(5100)or les+J WATER HEATER W/VENT/EL[CTR ENERGY FEE Y_ N_
I certifythal in the perfomenceof the work forwhlch this pemdt Is butted,
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PiQ.T. Dale Recei t#
Z U NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
should became subject to the Workers'Compemns atlon provisioofthe LeWr TOTAL: •.�
CC W Code,you most forthwith comply with such provisbm orlhis permit shall be BUILDING FEE
deemed revoked.
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
d G I hereby affirm that them Is a construction lending agency forthe perform ELECTRIC FEE
O Il ance ofthe work for which this permit hhsued(Sm 3097,Civ.C.) TOTAL:
U ndere Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Imrtifythat l have read this application and statethattheabove Information
O W tsconect.l agree to comply with all city and county ordinances and mate laws PERMITISSUANCE FEES PAID:
>_ S relating lobuilding construction,and hereby authcxar representatives of this
(_ V) city to enter upon the above-mentioned property for Wpedlon purposes. ALTERORADDTOMECH.
(WB agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V aga Wtllabilities,jYdg nb,carts and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga' tui try In ro ens of t granting of thio permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
7AMM
Sgnatureof Appicant/Contractor • DatT EXHUISTFIOODM/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO URE
Will the applicant or future building occupant store or handle haeardous IfEATINGUMT(TOIW,000BTU) Date RCCei [#
materW as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Ilealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 10,(X0 BTU) TOTAL:
0 Yes , MN. --
Will the appilrantorfuture Wilding occupant use No 1pment or device VENTILATION PAN(SINGLE RESID) ISS.32MATE
which cant ha,ardous air contamimets as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0(10 BTU) t
FI'��Ycs nNo
-Thome read the huar�i Oua materiab requirements underCFapter6.95 of BOILER-COMP(OVER 100,000BN)
the Califemia Iicalth&Safety Code,Sections 25505,25533 and 2534.I .L
understand that if the building does not currently have,tenant,that it is my NEW RESIDENTIAL MECH. SQ.FG � �CUOPI{TOO
nspmeallo ity to notify the occupant of the requirements which must be met F ' 1
prior to Issuance Of a Certificate of Occupancy.
Owner or authortud agent Data I �L/LILt
TO JAL:r
OFFICE COPY