20806 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PEFlMIT NO.
Building Address: "
�S / N 20806
�q amn: one: A A
/��GaNY a a4 CITY OF CUPERTINO-BUILDING DIVISION
LIc.No: APPLICATION / PERMIT —Z1;_q0
(�
7 92 BUILDINGELMnUCALPLUMBINC-MECHANICAL CATEGORY CONTROL
t - Arehlted/Fsglnnr. Lle No:
y-s,..7 '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PLUMB MICH
f,q Qn•�jV(' C� PERNUTISSUANCE
LICENSED C/ONVTRACTOR'S DECLARATION t—{�
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENIIIAL JOB DESCRB'HON
ing with Section 7000)Of IANtlon 3 ofthe Business and ProfeslonsC�de,and my
Bann Is In NU Iyy and effect. p 2Z PANELS
Class License Cla _` Lic.N LL 7 6 i y p sC`
Date Contractor Y VVJ1�
ARCHITECTS DECLARATION MI-1000AMP5
1gq+�0O I understand my plaroshall be usd as publicremrds. OVER1000AMPS SQ.ET.FLOOR AREA S/SQ.FT.
Limned Professional SIGNS ELECTRICAL
�<nt OWNER-BUILDER DECLARATION '
o� Iheabya(Orm that Iam exempt from the Contractor's License law for the SPECIAL CU[T/
70 following reason.(Section 7Q/15,Bu•ines and Professions Code:Any dry or pM OR .EI
< county which requirema permit tocorutruct,alter,Improve,demolish,orrepalr
YN Csi. anystructure pdortoltsissuance,alsorequires theapplicant for such permit to IOINTR DEVs
x-rG file a signed statement that he Is licensed pursuant to the provisions of the ,
(1�o'fn Contractor's License Law(Chapter 9(commencing with Section 7")of Divi- SWIMbBNGIVO EcrRkVALUATION
sion3o(the Business and PmfxalavCode)orthat he es exempt lherefromand
6 5the basis for the alleged exemption. Any violation of Section 7WI.S by any OUTLETSSVITC XH;RES
It
OO applicant form permit subjects the applicant to a civil penalty of net more than CtS[�
c. five hundred dollars($500). NEW RFSIDFNRAL ELECTR
�I,as owner of the prop.rty,or my empioyen with wages as their sole SQ.FG STORIES TYPECONSBLCTION
�7a compensation,will dothe work and thestmcture b not intended or offered for
.c
❑ vie(S .70p Buminns and Prefesiors Coda:The Contractors License Law
('y$� don not apply to an owner of property who Wilds or improves thereon,and OCC.GROMI RES.UNITS
0. who doessuchw°rk himsUorthrurgh his own employees,provided that much
improvements are not intended orofferod fondle.If,howeveq the building or TOTAL:
improvement bmold withinoneyearofcomplmiorythnownerbullderwlll have
t rdenofpmvmgthat he did not build or improve for purpme ofsale.). QTY, PLUMBING PERMIT FEE FT.00D70NE APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT 66IlANCE
contractions to construct the Project(Sec.70414 Business and Professions Code:
The Contractor'•Llcens Law don not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for so& ptojens with a
,,WIBSTactwW Ransed pursuant to the Contractor's Clans Law. FEE SUMMARY
dd LJ
BACK FLOW PROTECT.DEYICF.
I am exempt under Sec. B&P C for this reason OUTSIDE
J ejay Owner Dat° DRAINS FLOOR ROOF,AREA,CON[. SANITARY Y_ N_'
WOR KM N COMPENSATION DECLARATION FTX.Il1RFS PER TRAP SCHOOLTAX YRECEIPT
A �
01 hereby affirm that I have a certificate of consent to nlFinaum,or R_ IN
�,KILN
MOD,Lab
Cd aof Workers'Compensatl.nlruuranaonaartl(kd copythereof t5ec. GAS EA.SYSTEM-1 LNCAOUTLEIS PARK FEF. Y N
Palky 3800,
N RECEIPT N
Co y GASEA.SYSIFMOVER4(EA) BUILDING DV
1510\FEES
copy b hereby furnished.
copy b filed with the city city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF E(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEIVER-SAMIARY SIOIRM EA ImFT DatC Rece L#
(rhisseellon need non be completed tithe permit b forom hundred dollars
($tm)or,tifyt.) WATERHFATFRW/vFNt/m Till. ENERGYFEE Y N_
1 artily thatinthe pernm•nany work for which this Permitis c]scud,
I shall not employ any pawn In•ray rtoU. n as to become subject to the WATER SYSTEM/TREATING worker:Compensation Laws of Callfomia. Date PAID
licant
Z Z NOTICE TO APPLICANT:If,after making this C,,Alfiule of EzempOon,You NEW RF9DENIIAL PLMB. SQ.FT. Date Recei t#
O should become subject to the Worken'Compewtlon pmvbiov of the Labor TOTAL:
~ N C.dq you mustforthwith comply with much provisions orthis permit Nall be
W > deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE CM
CL Iherebyaf(Irm that there is a construction lending agency for the perform ELECTRIC FEE
= dna of the work for which this permit b Issued(Bec.3097,CIv.C.) TOTAL:
U O l<nder'm Name PLUMBING FEE
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerdfythst l have read tMsapplicati...W AiRethAthe aWve information
LU ecorretl.lagaemromplywuhaBdlyand countynrdinanamandrtalelawm PERMIT ISSUANCE FEESPAID:
r relating to building conatructlogand hereby muthortne representatives of this
F- U) city to enter upon the above-mentioned property(.,inspection purposes. , ALTERORADDTOMECH.
(We)agree t.sue,Indemnify an d keep hi rMcs the City of Cupertino Date Receipt#
V agalnmt Rabilitiea,j.dgm.ntqc.mtmandexpennawhich maylo anywayaame AIRHANDLING UNIT(TO 10,000CPNU SUBTOTAL:
agai Id GI Inc.esryven<e of the granting.f this permlL AIRHANDLINGUNTT(OVERIO,"CIM) CONSTRUCTION TAX
AZ {' CONSTRUCTION TAX PAID:
Signature.(App Hmador Date IXHALIST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will the dpphuefined t by the u pbuilding ocovpan oil, orhand 91Za and
HEATING UMT1701m,mOBN) Date Receipt#
micalth and SafinyCcx1S Cupertino Municipal Coda Chapter 91Z and the -
Iie 1 yesd Safety Code ct 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Z ISG
❑Yn
Will the harardntorfu contamldinginants
asdefi occupant use equipoxint At.devirn VFNHIAT104 FAN(SINGLE AFSID) ISSUANCE DATE
which emit haNardom air conlaMnanb as defined by the Bay Arca Air
Quality Management Di irkt BOILFR{ Ia OFRP
OMOR 100,000 BTU) P_A�pp��
Yu ro Pl
❑
[have read the harallous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BIL)
< „'c -the California Health k SafetyCode,Sections 25505,25S33 and 25534.1 t'
•"i b j understa rd that lithe building don not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. ju1
a responsibility to notify the occupant ofthe nequirementswhich must be,met
prior IoW c°ofa Certlficatc of panty. t� ` 7
t%1 c
g_2tyof Cuo?Ctino
Owner. authorized agent Date TOTAL: ISSUED RY: -
OFFICE COPY
_—