20776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentiH tion \ ^ /J PE tMH`NO.
Building Adders: �Y.l eC \ '^ /�O �1
UIICD ON U h/0 G
sere , P2 r /nj ^ one: A
001. d� /t lO Lue. o:j3� CITY OF CUPERTINO-BUILDING DIVISION '?—I ��qU
co actor',Name: APPLICATION / PERMIT 1
Oa-CQ7 BUILDINGELECTRICALPLUMBINGMFLHANICAL CATEGORY CONTROL Np/��
Architect/Engineer. Lic.No: tD L
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE 2� ❑
LICENSED CONTRACTOR'S DECLARATION
IMrebyafflren that l am licensed under provisions ofChapler 9(comeren APPLIANCES-RESIDENTIAL JOB DESCRB'TION
Ing with Sect ion 7000)of Division3 ofthe Buslnesand Professlon,Code,and my T
nx i,In fuB�mo affect
I'A}`IEIS 1
nx C6s 4SJ LIc.N
at157-4 p=�r(�Contnctor_ $ cuifr IJ7-IOW AMPS
ARCHITECTSDECLARATION' OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
m0 O I understand my plains shall be,used n public records.
Licensed Professlorei SIGNSELECTRICALf "? N-I "2-0.Qz
Q OWNER-BUILDER DECLARATION l C�l
fe Fii SPFC]ALCEtCUIT/M
F � owing affirm that on 7031exempt fromBusiness
a Contractor's License law Toy he
oo following irectlon7ml5,eonstruct and Profusions Code:Any cttyor
�ZI"'u9 countywhich requirsapemdttocorwmct,alter,improve,demolbh,orrcpair P. 61"[R ORI'O INST.
<��.'ti anystm=mpAortoltn Lasuancgal,orequlmtheappUmntfma chpermltto CES
re sir 6 file a signed statement that he Is Reensed pursuant to the provisions of the
3 ec G Contractors License law(Chapter 9(commencing with Section 7000)of Divi-
SWMA&COL E VALUATION
�,�OS elon3o(the Buslnessand ProfesWnsCode)orthat Fels exempttherefromand
p Q the Wats for the alleged exemption. Any violation of Section 7031.5 by any OUTLE.IS HFSA —9 f L U
;QJ 6X applicant lots permit subjects the applicant ton civil penalty elect comethan t t'C V
a g�i five hundred dollars($500). NEW RESIN AL EL
M I,as owner of the property, SIOWFS TYPE CONSTRUCTION
p perry,or try employee with wage,s their sole
k�Q compensation,wllldothe work andthestructurc boot Intended or offered for
5 O sle(see 70K Business and Professions Code:The Contractor's License Law
�$g docs not apply to an owner of property who builds or lmprovn therrorhand OCC.GROUP RES.UNITS
whodoes surhworkhlrrselforthreugh hlsownemployen,presided that such
improwenenbare not Intended oroffered for sale.If,however,thebuRdingor TOTAL: •]a,Q'�
Improvement 6 sold within ane year ofcomplellon,the owner-builder will have
t Nen of proving that he did not bund or Improve for purpose of tale.). QTY, PLUMBINGP RMT FEE FLOOD IDNE APN
LI,as owner of the property,am exclusively contracting with licensed PWjhIT ISSUANCE
contractors to construct the project(Sec.7014,Bushes and Profession,Code:
The Contractor's License Law does not apply to an owner of property who �rny-DRAIN&VENT-WATpt(E,U
Wilds or Improves thereon, and who contacts for such plojects with a
egntlactor(s)Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sea. B&P C for this mason
OUTSIDEFFES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
. Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
[]1 hereby affirm that I have a cortlflate of consent to self-Insure,ora RFCEPT I
cenRlczte of Workers Compensation Insurance or a certified copy thereof(Sec. CAS EA.SYSTEM-1 INCA OUTLL75 PARK FEE Y N
3800,lab Q
Policy N RECEB'T N
Cam ny GAS FA.SYSTEM-OVER 4 MA) BUILDING DIVISION FEES
CertBled copy 6 hereby furnished. CREASE/INOUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EKEM PTION FROM WOR KERS' GREASE TRAP PAID ^� __^7/
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017. Date Recti t# L tD
(TM„ectlon need not becompleted If the permit Isforam hundred dollars
le
($1 W)or an.) wATERHEAT'Etw/vENT/E.ECTR ENERGYFEE Y_ N_
I mrtify that In the performance of thework forwhich this permit b Issued,
I shall not employ any person in any manner w s to become subject to the WATERSYSTEM/]TREATING
Workers'Compensation lawn of California.Date PAID /'yam
O Z Applicant NEW RESIDENTIAL PCMB. SQFT. Date Recti t# so,CO
Z O NOTICETO APPLICANT:If,after making thisCertificate o(Exemptlon,you
should Wcome,ubrct to the Workers Compunsatlon proWlons of the Labor TOTAL:
� (A code,you at forthwith comply with such provisions or this permit shall be BUILDING ••G
W > decrrcdrevoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE a
CL Ihereby affirm that them baconstructlonlendingagencyfortheperform ELECTRIC FEE d'O
7Z anceoflhework forwhichthis permit Is Issued(Sec.3097,Cie.C.) TOTAL:
d O Leruler,Name PLUMBING FEE
IL H LendersAddreas QTY. MECHANICAL PERMIT FEEMECHANICAL FEE �i f�
U Icertifythatl Wvemadth6appliratlonand Cm
atuthattheabourmfoution
QW llciIT is agree to comply with atyand courtyordieancosand statelaws PERMISSUANCE J)'CV FEES PAID:
>. a rclaungmbuilding construction,and hercbyauthorlu representatives olth6
Z dtyto enter upon the above.mentioned property(or
on
rposes ALTER ORADDTO MEC}i. '�s�'
_ Date Receipt#
(We)agree to save,Indemmily an d keep harmless the y of Cupertino AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
V agalnst166i In,pdgments,mCi and ex nxa which 4,I nywayaccrue
against si styIn consequ oft uetiZ1.1ng oft It.
,vA1IANouNc ublrl(OVER F0000cFkN) CONSTRUCTION TAX
grarcof App ram contra r EXHAUST HODD(W/DUCT) CONSTRUCTION TAX PAID:
HAl RDOUSMATERIALS UISCLOS RB
Will the applicant or future building occupant store or handle li aardous HEATING UNIT CEO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 j and the
I lealth and Safety Co n255 Biy? HEATING UNIT(OVER 100,000 BTU) TOTAL: a
❑ Ye o
Will the applicantfuture building occupant use equipment or devices VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air
. Quality Marugemerd 6tmt? BOILER-COMP MIT OR I00,OW BTU) PPJ®
4Yn o
have read the Nazar ousmaterialsmqutme nbunder Chapler6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health fury Code,Sections 25505,25533 and 15530.1 p p '�qq
u odersta nd that if the building does not co rrently have a to gthat it is my NEW RESIDENTIAL MECH. SQ.FI'. •1 4 kf- 1 V 1990
mponsibilityt nollfythe occupant of the requirementh must met
priorloucui c ofa Certlfiratuof Oc Per /
Aty
ser authorised agent D N ISSl1ED BY:V k/U/i��?te� -'Q6
TOTAL:
OFFICE COPY