19915 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proect Identification PERMIT NO.:
Building Address:. _ : _ ., - .. _ 1 991 5
Phone: AITLIXFON SU ` A
CITY OF CUPERTINO-BUILDING'DIVISION
co m' ams Lit.No: - APPLICATION / PERMIT /
BUILDINGELECTRICAI.-PLUMBINGMECHANICAL - CATEGORY CONTROL X
Architect/Engineer. Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrev:
=TISSUANCE ❑ ❑
LICENSED CONTRDECLARATION '
Ihltcenseunderprovisions ofChapler9
immanent, APPLIANCESRESIDENIIAL JOB DESCRIPTION
IngwithSechon7OUD)ofDivikon3oftheBukinemandProfesioneCodenand
my
license is In AiNfgrreayd d(et PANELS
License Class Lie.X
Date(fffg_�Contractor C�1"ix1e &,01 •
Xr ��� ^�ARCHITECTSDB R TION 201-10DOAM'S
pQ±02 I understand my plamshallbe used as public records. OVERIDDOAMPS SQ.FT.FLOOR AR SR.S/ FC.
E (d Licensed Professiorol - SIGNS ELECTRICAL A '
L�nu OWNER-gNLDER DECLARATION SPECIAL UIT/MiM 40 -
f., � Ihereby affl mthat l Mexempt from the Contractors Llconse Law for the
024,C)❑ following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.M O -
F� county which requires a permit to mrutrue"ter,improve,demolish,orrepor
any structure prior to Its Issuance,also requires the applicant for such permit to r ]iDWERDEV]file a signed statement that he is pursuant to the provisions of the
3wf� ContractoYs License Law(Chapter 9(commencing with Section 7000)of Divi- C
ti�O:f sion3o(the BusInesmdProfemlom Code)orthathelsewmpttherefmmand VALUATION '
•]] the basis for the alleged exemption. Any violation of Section 70313 by any ETS-SwITC ��
appHeant Furs permit subjectathe applicantm a civil penalty of nm mum the
f1 J�undred do1Lre(5500). NEW RBsFD E pG SQ,FE. STORIES ECONSTRUCTION
�n u I,ee owner of the property,or my employees with wages as their so
compensation,will do the work,and thestmcture is not Intended or offered fo
Osale(Sec.7044,Business and Prof naimu Code:The Contractors License law
$ does not apply to an owner of property who Wilds or improves thereon,and
whodoeesuchworkhlmselfmthreughhisownemployms,provldedlhatauch If OCC.GROUP 'RES.
UMTS --
improvements are not Intended oroffered forsale.](however,lhebuildinger TOTAL:
Improvement is cold within omyearofcompl&bN the owner-bu0derwBl have
f - tlturden of proving that he did not build or improve for purpose ofsale.). QTY, PL BING PERMIT FEE FLOOD 711NE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .
contractors to mrstruct the project(Sec.7064,Business and Professiom Cade:
The Contnctor's Licence Law does not apply to an owner of property who
Wilde or Improves thereon,and who contracts for such pcojects with a ALTER-DRAIN -WATER(EA)
coJJLLt((aaoKe)licensed pursuant to the Contractor's Llceme Law. FEE SUMMARY '
Off,am exempt under Sec. B&P C for this reason BACKFLOW PROTECT.DEVICE
OUTSIIJFFEES
DRAINS.FLOOR A,ROOF,AREGOND. SANITARY Y - N_
• Owner Date RECEIrf X—
WORKMAN COMPENSATION DECLN
❑I h
ereby,e!(Irm certificate that I have a of consentsentto to eel(-InwFIXTURES•PER TRAP SCHOOL TAX Y N
re,or
certificateRECEIPT X
of Workers'Comperuatlon Insurance or a certified copy thereof(Sec, GAS -1 INCAOUTLETS '- PARK FEE Y N
3800,Lab C. RECER'f X '
Po11cya 6 �. '+ GAS S -0VFR4(FA)
2oG��a7.��
Com any r aye /Ya�/�-�O�I'/�'��� - BUILDING DIVISION Bees
Certified mpy by rthe cit. G WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS'
PAID' '
COMPENSATION INSURANCE RM EA 200FT Date Reset t#
(Tnlssection need not be completed if the permit efor one hundred d
(9100)orlev.) w w/vFxf/ELECTR ENERGY FEE Y N
[certify that In the performance of the work for which this permit is
I shall not employ any person In any manner so as to become subject o SYSTEM/TREATING `
Workera Compensation Law.of California.Date PAID
III'Z 2 Applicant RESIDENTIAL PLMB. SQFT. Date Recei t#
O NOTICE TO APPLICANT:If,after making this Cotificateof Exemption,you
should become subject to the Workeri Compensation pmvlslom of the Labor TOTAL:
Code,you at forthwith comply with ouch proviimu mthls permit shall be
W > deemed revoked. - BUIL ING •E 7.0
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there is a construction lending agency forthe perlonry TOTAL: ELECTRIC FEE
:3Z ante ofthe work forwhlch this permit is Issued(Sec.3097,Civ.C.)
U O Lenders Name PLUMBING FEE
LL Lender'a Addm.a QTY. MECHANICAL PERMIT FEE . .MECHANICAL FEE
O W bcoIcolifythat I have read this applicatlonand exatethalthe above Information '
rrect.i agreeto complywlth all city and munty ordinances andstatelaws PERMIT ISSUANCE FEES PAID:
1
Y N rcI.ting to building construction,and hereby autharize representatives of this ALTER OR city to enter upon the above-mentioned property for inspection purposes. ALTOR ADD TO MECH. .
2 (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,jodgmenle,mks and expenses which may in any way accrue AIR HANDLING[IMC(TO I0,ODO CFM) SUBTOTAL:
a 1said City in coroxf (th grant of this permit CONSTRUCTION TAX
AIR HANDLING UMC(OVER 10,I00CFM)
S Wmof Applicant/C cat ctor to EXHAUSTHOOD(W%DUCT)' CONSTRUCTION TAX PAID:
HAZARD USMATERIALSDISCLOSURE
Will the applicant or re building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) - Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Healthand Safety Code Se 532(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL: st'
❑Yee ' L
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) A'AISS ANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Mareprrent Distil BOILER-COMP(3HP OR 100.0(0 BTU)
4Yea �(���`cft}oy �y 'y
havereadthehazaV-1.aterlalsrequirements under Chapter 6.95of BOILER-COMP(OVER IDO,000BTU) 1+ rn 1 U tyj(f
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. 5QFC.
responsibility to notify the o�p'ntof the requircmentawhlhmust be met eI/y of cute �
prI p issuance oda Cpgific e f ff n �� ��tal N. Rny
Date ent gISSUEOB
.
' o 1Fil/Cr%IlrtCw'+'`tet O,IC�-F'�(l7
er or authorized ag -
TOTAL:
OFFICE COPY