20759 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Buildingoat his 20759
Wnefa /'� PhOn[:
CITY OF CUPERTINO-BUILDING DIVISION
onlractoes ame: Lk.No: APPLICATION /PERMIT
BUILDING-ELECnUCALPLUMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lt.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Addrcv:
PERMITISSUANCE ill ❑ 1:1 El
CONTRACTOR'S DECLARATION IJJ
withSydfkm that iv Bceneedunder lusine laloneot Csslons9de,and nc- APPLIANCESRESIDENTIAL ]OB DESCRETION
inglicemeh In
and effeon3ofthe BuainevandProtevloneCode,and my
Lt..Isln fuB farce and effect. PANELS
Danse Class Lk.p
Date Ca truchm "Tr' ml
TECT
ARCHITECPS DECLARATION 2011000 AMPS
qua aOZ ]understand rtry phro shag beu.d vpubllc records OV (X10 SQ.FT.FLOOR AREA 6/SQ.FL.
k U� Llcen ed Professional SIG TRI AL
eiQ6LG'r7 OWNER-BUILDER DECLARATION SPECIAL UIT/
Io„ IherebyalRrm that l am exempt from the Contractor's Llan.Law loathe ,
OgfoBowingreason.(5ectian7031.5,Buafnessand Professions Cade:Anycityor TEMP. O EI
Py county which requlresa permit to construct,alter,improve,derrlolbh,orrepalr
$q Q anystm=mpdortolhh.ance,atsorequi theappBentfarauchper tto
{ ryG V Bk a signed statement that he it licensed pursuant to the provisions;of the
3w� Contractor's License tawfChspmr9(ammenctogm),Section 7000).1 Divi- GPOO L EL C
�Og elon3o(the BuaNeu and Prefe.broCode)orthat he lsexempttheretromand VALUATION
< the basis for the alleged exemption. Any violation of Section 7a3IS by any O TSSWITCHES l i �/ Oma l
appBrant fora permit sub)muthe applicant to a dull penalty of not mre othan tJ[/
flue
ndred dollars($500). ESIDENIIAL L .FT. STORIES TYPECONSTRUCTION
�n oas owner of the property,or my employees with wages as their sok
mperoatlon,wllldothe work,an lthe structure h not[Mended or offered for
Oelle(Sec.7044,Buabien and Professions Cade:The Contractors License law
$ does not apply to an owner of property who builds or improve,thereon and OCC.GROUP RES.UNITS
who doessuch work himself or through his own employee,provided that such
Improvenpnh are not intended proffered for sale.If,however,thebullding or TOTAL:
Improvement b.ldwithlnoneyertefcompldloo,theowner-buBderwlll have
tlikurden of proving that he did nm build or Improve for purpose otukJ. QTY, PLUMBING PERMIT FEE FLOODZONE APN
Lj L as owner of the Property,am exclusively contracting with[lensed PERMIT ISSUANCE- -
antradms to construct the project(Sec.70/4,Business and Professions Code:
no Contractor's Llanst taw don not apply to an owner of property who AL•1tBR-DRAIN AVENT-WATER(EA)
Wilds or Improvm aro thereon,and who ntrafar such p(ojects with a - FEE SUMMARY
.gpt[ador(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under See B k P C for this rca.n
* DRAINS FLOOR, , , . OUTSIDE FEES
SANITARY Y N
-� Owner Date ROOFAREACONDRECBB'IX
WORKMAN COMPENSATION DECLARATION F7XIlIRES PER TRAP SCHOOLTAX Y N
❑I hereby aHlrm that I have a certiflale of consent to.B-Inure,ora - RECEB'I'X
certi0ateofWorkers'Compensation lruurame or. riffled copy thereof(See. GAS EA.SYSTEM-1 WCAOU7LETS PARKFEE Y N
3800,1.6C.) RECEII'I X
C. p GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Com any
ffCzVud copy is hereby famished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
MCchifted spy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Reeei tot
(Thle.ctlon need not be completed Rthe permit Is for ane hundred dollars
($100)orlesaJ WA•Ivet En.[m W/VFNI,/ELECT•R ENERGYFEE Y N
I permit that In the perform nee of the work far which this pedt is hsved,
I shall not employ any,person In any manner so m to become subject to the WATER SYSTEM/TREATING
Worken'Compenutkenta.MCaRfomia.Date PAID
Z ApplicantNE-W REEDEJ•f1�p�g, SOFA, Date Revel t#
Z O NOTICETO APPLICANT:If,after making this CertVicate of Exemption,you
should become subject to the Workers'Comp[roatlon provisions ofthe Labor TOTAL:
N Code,you most forthwith amply with such provisions orthisp rentehalt be BU
ILDING
LM j deemed revoked.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE r�
CL I hereby affirm that there as a construction lending agency forth,perforam TOTAL:
ELECTRIC FEE
7 b Z ance ofthework forwhichthis permit icmed(Sec.3097,Clv,C,)
V O Lender4Name PLUMBING FEE
F Lender.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW Icertlfythmlhave readthisappllatbnand statethatthe above lnforrtutian _
1 beorrect.I agree to comply with all city and aunty ordinance and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authoriz.representatives ofthis
Z city to enter upon the abowreentioned property for InspectionEtpection purposes. AL1* ORADDTOMECH.
F
V Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReCel 171
egaWt Babllltles,judgments,aYe and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ty In ansequ f the granting of this permit.
? AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
5 reef pplia rads EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI eapplicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rmci tit
milasdaf by the Cup<rtlno MuMdpal Code,Chapter 9.12,and the -
IkalthandSafetyCode Ion 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RY.
ill the applicant or afore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haz.rdous air contaminants as delisted by the Bay Area Air
Quality Management District? BOILER-COMP OHI'OR 100,000 BTU)
4 ��
Yee o
yon
BOILER-(OMP(OVER100,000 BM
the Mfomla Health A Safety Code,Sections 25505,75533 and 25534.1 JUL 16 1 90
understand that lithe building don am currently have a tenant that it is my NEW RESIDENTIAL MECA. SQ.FT
rnpom I fast th pant of the requkertats which mustbe t
pr r uan Ica of Ocaupanry. -
7 o Cil QB:_ a
ner authoriudagent Do TOTAL: ISSUED BY:
OFFICE COPY