19774 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro�cat Identification PERMITNO.
°°'io�3 19 7 7 4
Namek� r A n A
m\ o ��R�GF� rJ CITY OF CUPERTINO-BUILDING DIVISION �^
/'• a p`Namc: LLiccNN : APPLICATION / PERMIT z V
\ \ 7IntT Q ir^ &� BU)LDINC—ME RICAI PLUMBINGMMC LAICAL CATEGORY CONTROL
Architect/Engin . Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
`• Address: PERMITISSUANCE ❑ EEEZ71 MH
El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth SectionR )of Divislon3ofthe Businnsand Pmfesslons Code,and my
license Is in( f d effect �- O PANELS
It
✓{� A �r�
Lice Cl Llc.
Date Contractor n� —UP TO 200AWS
ARCHITECPS DECLARATION 201-1000AMP5
00X I understand my plan shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
❑O❑
r Q`j Licensed Professional SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
I lumbyafBrmthat l am cempt fromthe Contractor's License Law for the SPECIALCIZCUIT/MISC
'T0-" lollowin reason.(Bedlon 7m1.5,Business and Pro(esdbn Code:An nt or
FZFp'� county which requires a permit to contract,alter,improve,dereolbh,orrepair TEMP.METER ORPOLE INST.
�MS¢ anystructure priorto ltstawance,al,a requiresthe applicant for such permitto p0$yER DEVICES
c.O file a signed statement that he Is licensed pursuant to the provision of the
Contractor§License taw(Chapter9(mmmeneingwith Section 90W)o(Divi.
F•�O� too3ofthe Buslnessand Profession Code)orthatheberempt there(romand SWIMMING POOL ELE VALUATION
the basis for the alleged exemption. Any violation of Section 9031.5 by any
?3w<5
applicant fora rmltsub' thea li ttoa civil 1 of not more than OUTLETSSWITC
fvP ol Mets PP can peaty
c.:o five hundred dollen(5500).
1,as owner of the NEWR IDENTIALE SQ SFORIES TYPE CONSTRUCTION
?�n property,or he employees with wages r their door
C ¢ compensation,willdothaworkandthesCde:TheCntractrure is not Intended o License
Law
d for
sale(Sec.7014,Business and Profession Code:The Contractors Llmne Law
does not a pply to an owner of pmperty who builds or improves t hereon,and OCC.GROUP RES.UNrrs
-- whodocssuch workMmselforthtough hisownempioyees,provided that such
improvements are not intended oroffered for sale.IL however,thebuilding or TOTAL:
improvement issold w)lhinoneyearofcompletlon,Theo vorr-builderwill have
tirjiuden of proving that he did not build or improve for purpose of sale.). QTY, IN PERMI FEE FLOOD ZONE nrN
LJ L as owner of the property,am exclusively contracting with licensed rFRMLT ISS NCE
contractors to contract the project(Sce.7044,Business and Profeasion Code:
The Contractor's License Law don not apply to an or of property who ALTER-D & W
Wilds or improved thereon, and who contracts for such ptojects with a i )
[[1111(tactor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
e[51 am exempt under Sec. B&P C for this reason BACK FLOW MOTIENT-4EV14 OUTSI DE FITS
-4 Owner Date DRAINS FLOCK F, GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION pp(NRES PER TRAP SCHOOLTAX RECEIPT
Y, 1] n
I hereby affirm that I have a certificate of consent to self-iure ora RFLFR'F M
i ir[t[ Aificateof Workers CompenationlnuranmoraunifiMmpythercof(Sec. GAS F.A.SYSIT]d-1 INCA 0 EIS PARK FEE Y' 'T
ro.?4t 3800.Lab C.)•1}'p, ,.`ys,,.` (��� If
_
ComryanlY1C?Z�T-' GASEA.SYSFEM-0VER4(EA) DING DIV
I y BUILDING DIVISION FF.FS
�Ifled copy b hercbytumecity CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
edified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SLWER-SANITARY-STORM EA.20OFf. Date ReCCI [N
(this section need not be completed if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
I¢rtify that In the pedormanm o(the work forwhich this permitbissued,
I shall not employ any pemon in any manner w m to become subject to the WATER SYSTEM/TREATING
Workers Compensation Law,of California. Date PAID
Cl Z Applicant I NEW RESIDENTIAL PLMB. SQ.FT. Date RCWI Ifl
Z O NOTICE O PPLICANT:I(,aher making this Certificate of Exemption,you
H y should becomesubJed to the Workers Compereadon provision of the LaW, TOTAL:
Code,you must forthwith comply with such provision orthls permit shallbe
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a ° I hereby affirm that there is a construction lending agency for the performELGCTRIC FEE.
7 Z anm of the work for which this permit is Issued(Sec.3097,Civ.Q TOTAL:
V O Lenders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IscoImet III,that l have read t hbappllcadona M tat—that thc.imm information
1 rrect.I agree to comply with al city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID
T N reauthorise representatives to building construction,and hereby authorirepresentatives of this
F_ Z cityto enterupon thoaWve-mentioned Property for inspection Purposes. ALTFRORADDTOMECH.
_ (We)agree to sive,Indemnify an d keep harmless the City of Cupertino - Date Receipt#
against liabilities,pdgments,costs and expenses which may In anywayaccue AIR HANDLING UNIT(TO 10,000 CFM)
aga int said City In m�aryuence of the granting of this pennR. SUBTOTAL:
0 MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bullding occupant store'or handle hazardous HEATING UNIT(TO 100,0006TU) Date Recei IN
matelot as defined by the Cu Ino Munidpal Code,Chapter 9.12,and the .
H,Ahend Safety Code on25532(a)9 IIEATIN'G UNIT(OVER 100,000 BTU) OTAG fl
nYes N'o - •
Will the applicant or future building occupant use equipmentordevires VENTILATION FAN(SINGLE RESID) ISSUAN TE
\ which emit hazardous air costa antsasdefrrdbytWBay Area Airs+�—
QualRyManagementDist u BOILER-COMP OHP OR 100,000 BTU) /s
4 Yes o
have mad the Naza s materlab requirements under Chapter 6.95 of MOILER-COMP(OVE[t 100,000 BTU) PAS
J y` the Calife rola Flealth&Safety Code,Sen ion 25505,25533 and 25534. I ��•
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT.
repo ibility to notify the occupant of the requimrvnb which most be met
p for suanm of Ce
rti(i leeOccup nary.
y or authorized agent at ISSUED � AlL'�/ CJ
TOTAL:
OFFICE COPY