19547 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ext Identification PERMIT NO.
Building Address: 1
Z i ` (o ✓ f fAoA 15 PD C l7L , I
seers 1—me Phone: A A
cA If 4-7 CITY OF CUPERTINO-BUILDING DIVISIONAm _ D
eontraetoraName: Lie.K& APPLICATION / PERMIT
LIc.N. BUILDINGELECnUCAI PLUMBINGMECHANICAL CA RY CONTROLM��O
Mteyt/� n r.
(7,� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Akh7 01—ICOIW AY PERMITISSUANCE 1s�
MITH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam Bcensed under pmovislonsof Chapter9(commenc APPLIANCESRESIDENRIAL BDCSC ON
IngwithSMlon 7ODO)of Division3ofthe Buslnessand PmfeaslonsCode,and my
LiceraseCla.in ll fora and effect. PANELS 1 �'ie�
license Cyan Liff c NII V
Date Contractor LTIQZMAMPS r\ — 74
ARCHITECT'S DECLARATION W_SQj
S
reO Zp I understand my plow shall be used as public records. MPS SQ.FT.FLOOR AREA 5/SQ.ET.
U(D Llrenud Professional RIC L C ' / / - ell-
< OWNER-BUILDER DECLARATION CU[ o l4,'
!hereby affirm that l am exempt from the Contractors License Law for the
0...'a following reason.(Section 7031.5,Business and Professions Code:Any city or /F�F'� muntywhichrequlresa permulocomutrua,alterlmprovedemolbh,compair TDA OR 7� anystmumprmrtoltslssuame,alsorequimstheappllrantforouchp.r tto !file a signed statement that he b licensed pursuant to the pe,vislov o! theContractor's License Law(Chapter9(commencing with Section 7000)of Divi- Lslon3 of the Business and Prefesslons Code or that he b exempt therefromandVALUATIONlitydS thebasb for the alleged exemption. Any t tolabn of Semon ex31.5 by a y pZ r /{%o r (JappBantforapermlt subjectstheappllcanttoacivllpevlty o(not morethan t0 � ofive hundred dollars(,M.
�I,as owner o!the property,or my employees with wages as lM1elr sale AL � SQ� STORIES TYPE CONSIRUCt10N
k < compensation,will do the work and thestructume in not Intended or offeredfor I
$ O
Is(Sec.7014 Business and Proferosslons Code:The Cmdractols Llttrue Law V
$ does not apply to an owner of property who builds or Improve thereon,and
who doessuchwork him elf orthruugh hisownemployees,provided that such OCC GROf1P RFS.UNITS
ImprovementsarcnoHnlendreyearfnredfor sale.throwevcgilderwdingw TOTAL: �? /
improvement am not
tintnded or ffecompletion,theowe,verthebuilll have
t Iden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE pLoG, zoNE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to amearect the project(Sec.7014,Business and Profenlmis Code:
The Contractors License law does not apply to an owner of property who x
Wilds or Improves thereon, and who contraM for such pAojech,with a ALM-DRAIN k VENT-WATER(EA)
cc tt[[actor(s)Ilmnsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI[am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ NOuTsin�
. WORKMAN COMPENSATION DECLARATION RECEBxTp
01 hereby affirm that I have a certificate of consent to self-insure,or F7%TURFS TER TR AP 't(A SCHOOLTA% Y N
cxniflate of Worken'Compevation Insurance ora certified copythereof(Sec. RECEIPT#
3800,Lab C.) GAS.EA.SYSCEM-1 INCA OUTLETS TT PARK FEE Y N
Policy# Ot/ RECENT#
Com any GAB-EA.SY9TQ OVER4(FA) BUILDING DIVISION FEES
HCenified copy b herebyfurnished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CenJed ropybfibd with the sty inspection division. Gu c
CERTIFICATE OF IXEMPDON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhiswdt nneednmt completediftheper tbfmonehundreddollan SEWER-R-SAMTARY-STORM EA.20017T. Date Retmi t#
($100)ar len.) WATER HEATER W/VENT/ELECT# ENERGY FEE Y N
I cenlfythat N the performance of the work forwhich this permit is based,
I shall not employ any person in any manner oto as to became subject to the —
Worken'Compensation Iowa of Callfornla.Date WA'C[Bt SYSTEM/TREATING PAID
O Z Applicant //'' //``
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDEN7IAL PLMB. SQ.FT, Date Recei t# ppb cc
should becorcraubjeett.the WmIxers'Campensatlon provisions of the Labor
WW Code,you most forthwith comply with such provisions orchis permit shall be TOTAL:
> deemed revoked. B ILD NG -E .C-0
d p Consrgurnons LENDING AGENCY , SEISMIC FEE ,
I hereby affirm that there i a construction lending agency forthe pedorro-
Z aneeofthework for which this perMlbIssued(Sec.3097,Civ.C.) TOTAL: .0ELECTRIC FEE
0 L Q
LL O Lenders Nam PLUMBING FEE
LL h- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W correct.
I hatl agrees comply
with aliationanddc state ordinances
information
4 is to comply with all and county and state laws PERMIT N00 FEE-PAID
} N relating to building nstruction,and hereby authorize representatives of this
N co
Z city to enter upon the above-mentioned property for Inspection purposes. r ALTERORADDTOMECH.
- (We)agree to save,Indemnify..d keep harmless the City of Cupertino `� Date Receipt#
against liabilities,judgments,costs and expenses which may in anywsyace,on AIR HANDLING UNIT(TO 10,D30CFM)
against said City in consequence of the granting eff this permit. SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigmture of AppBant/Contractor Data IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapphant or future building occupant store or handle hazardousHEATING UNIT(TO 100,000 BTT!)
materials,defined bythe Cupertino Municipal Code,Chaper9.lZ and the r Date RCCej t#
I lcOalt Yesd Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑ TOTAL: )
Will the applicant or town,building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which cared hazardous air contacdnsnb as defined by the Bay Area Air a J
@+ Illy Management District? BOILER-COMP pHPDR 100,IXD BTI!)
4 Yes No
have read the Nazar us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000BN) �t ps{���
the Calilornla I lealih h Solely Cade,Sections 7550.5,75533 and 25534.I rBn
understand Out lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. '^=L
responsibility to notify the occupant of the requirements which most be met ^ ��ry
Prior to Issuance da CertiOate of Occupancy. JJ� `t
Owneror awize
hord agent Date `'+ pyo 1ys� l
TOTAL: ISSUED BY:w`�'�IlY7t— Lm ,[
OFFICE COPY