20144 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Address: - 0 A A
D N, r� M 4 4
vera 01r1e: One:
A t91UGi9 M A/C
Cb, ytp- y / CITY OF CUPERTINO-BUILDING DIVISION �D
G°°^tr nn'shame: Lie.No APPLICATION /PERMIT `C t7
V BUR.DING-ELECTMCAT PLUMBINGMFCFIANICAL CATEGORY CONTROL 8
Architect/Engineer. Lk. o:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE „❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamlicensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL JOB DESCKI'HON
Ingwith Section7000)of Dlvision3 ofthe Businessand ProfessionsCode,and myIt '
License LWmlnforce andeffect. PANELS
License
Conte 1.4'o(oeN
Dare ._ Contractor /�—�'�ry�.. 2011000AMPSre v
ARCHITECTS D ION v
0ZCC lundentand myplansshallbeused aspublierecords OVERl"AMPS 1 SQ.FT.FLOOR AREA $/SQ.FT.
U Licensed Professional I G A
G OWNER-BUILDER DECLARATION _ -
Zs, '7p Iherebyaffirtnthatl amexempt fromlhe Contractor's License Lawforthe
W following reason.(Section 7031.5,Business and Professions Code:Any cityor
countywhich requlresa permittoconsmId,alter,improve,denwilsh,orrepa r LNST,ev
anystructure prior to its le.uame,also requirestheappliant forsuch permit to
ruG file.signed statement that he is licensed pursuant to the provisions of the
O w{� Contractor's License law(Chapter 9(commencing with Section 7000)of Divi-
�OJ Aon3ofthe ButlnnsmdProfe.eicm Code)orthatheisemmpttherefromand WRriMING POOL ELECTRIC VALUATION
•77 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIIFSFIXT[IRFS S�
G appliesntf.r.permitsubjeeatheapplicanttoadvilpemityofn&=mthan
o five hundreddollarsof hepr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
GGGIII ❑I,as owner of the property,or my employees with wages as thele door
.1.(3ccompens70Kation,Businessl do work,andPfos the sC dure is he ot Contractors
or License
d for
Law
q doesSec. pply to Business andf property Code; Contractees License Law
don not apply torn owner of property who n em o yeas,provided vv tfiereory and hat such OCC.GROUP RES.UNITS
a whodcem nts am kMmee f or dedoraffered owns.If,ho es, eb building
or
Improvements arenot intendedprofferedfor sion.It,hmvever, fldar ldingve TOTAL: 1
Improvement is sold within omyearofcompletion,the ownervbullderwiil have '
Cllr nrden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
II 1,as owner°f the property,am exclusively contracting with licensed ppJ�$pp ISSUANCE
contractors to mretrud the project(Sec.7094,Business and Professions Code: -
no Contractor'.License law does not apply to an owner of property who ALTER-DRAIN&VENT=WATER(EA) --
builds,or Improve re
theo ,and who contracts for such plejects with a FEE SUMMARY
cgB((ador(a)licensed pursuant to the Contractor's Lkense Law. BAIXFIAWPROTECT.DEVICE-
LI I Om exempt under Sec. B &P C for this reasonOUTS[DE FEES
Owner Date DRAINS FLOOR ROOF,AREA,ODND. - SANITARY Y_ N_
.RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCI;DOL TAX Y_ N_
[:]I hereby affirm that I have a certificate of convent to self-insure,ora RpOp�rp#
comfiate ofWorkers!Compensattoolneurance ora certified copytherecif(Sec.
3800,Lab C.) GAS EA.SYBTEM-1 INC.40UTLE75 PARK FEE .Y N
RECEIPT p
Policy# GAS EA.SYSfFM-OVRR4(EA)
Cam any BUILDING DIVISION FEES
❑pCeAtfied copy b hercbyfurnished.
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy b filed with the city Inspection division.
t GREASE TRAP .
�.
CERTIFICATEMPE SATION INSON MOMINSURANCE
KERS' PAID
COMPENSATION INSURANCE SEWER STGKM EA 200BT Date Recei IN
(Thissedion need not be completed if the permit Is forces hundred dollars
($1M)mIess.) WATER HEATER W/VENT/�I.ECTR ENERGY FEE Y_ N
I certifythat la the performance of the work forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYST.FM/TREATING
Workers Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB, SQFf. Date Recei tp
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should be...ubjectto the Warkeri Compe..tim provisionsof the Labor - TOTAL:
CC W Code,you must forthwith comply with such provblom orthb permitshall be BUILDING 'E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d 1] Ihereby affirm that there b a construction lendingagency for the prdorrtr TOTAL: ELECTRIC FEE
U Z arts of the work forwhich this permit td issued(Sec.3097,Civ,C.)
V O [ender'sName - PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WIcertdythatlhavemadlhisappUmtlonand statelhattheaboveinformatlan
lSMMd.I agmetocomplywilhallcilyand county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
} 0. relating to building construction,and hereby authorize representatives of this
N dty to enter upon the above-mentioned property for impection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Reeeipt?I
V against liabilities,judgments,cone and expends which may In any way seems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agaJagjaid City In con en o�the granting of this permit
(A/ 1/ �r`%A p AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
�jt��y____���•{�;(�jrLJ YC CONSTRUCTION TAX PAID:
Slgmum of Apptlant/Contractor Date EXHAUST HOOD(W/DUCT)
HAM RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code Sedion25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes , MN.
Will the applicant or future building occupant use equipment or devicos VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air �w.�
1
Quality Management District? BORER-COMP OHP OR 100,000 BTU)- '#7/
4We ❑No
haveres the Health&Safety us Code,Se requirements under Chapter 6.95 of BOILER-COMP(OVER 1m.fxlo BT?A 'APD L
the California Healih&Safety Code,Sections 25505,25533 and 25534.1 fi 7
understand that if the building does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQTT.
responsibility to notify the occupant of the requirements which must be met p,L-0�
prior to issuance of a Certificate of Occupancy. aly.
pancy.
Owner or authorized agent- Data TOTAL: ISSUED B
OFFICE COPY