20617 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES =USE BALL POINT PEN ONLY '
Build in Pro en Idemiflation. PERMIT NO. • -
Buildmi;Address: - ..
as 9r lit
20617
wne eros: - - one: A A
CITY OF CUPERTIN6BUILDING DIVISION
o APPLICATIONIP.ERMIT
-Z
/ _BUILDING ELECTRICAL-PLUMBINGMECHANICAL CATECORY CONTROL a
t'
�. Architect/Engineer.-" - Lle No: -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address * - PERMITISSUANCE ❑ �- .
t=that
LICENSED CONTR under rDECLARATION o ,
]hereby affirm that lam licensed under provisions o(Chaptcr9(mmmena APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlthSecton70f10)of Division3ofthe BuMmmand Pmfemion°Code,and my - - -
Ilcense Is In Nqq(o�F d effect. PANELS -
Llcen Class CsG Lic.M"-a � �.�� -
Date, �Contraamr$J—'
ARCHITECT'S DECLARATION ;SIGNSELEWC
AMP5 i
rs�ZO. Iundentand my plans sial be used upub0crerords 00 AMPS SQ,FT,FLOOR AREA S/SQ,FT,,
L (y
F• Licensed Prof ZemlovlL< OWNERex rcpt Tru DECLARATION - ` LCI2C T M[herebya(firmtfiatiamesempt(romtheContrador'sLlcensslawforthe following reason.(Section 70315,Business and Professions Code:My city or OR L 7countywhich requires aperrtdtromtutrua,alter,Improve,dennlbh,orrepalranystmct mprlortoltsl manceaborequimotheappll®ntfor°uchpermltto Jj
file a signed statement that he is licensed pursuant to the provisions of the
Contractm',License Law(Chap 9(comm mob g with Sect1On 7000)of DbJ_ gMhgN C
' k350S sion3 of the Ruslnensand ProfesslonsCode)orthat heh caempttherefromaM EVALUATION, ,
the bash for the alleged'exemption. My violation of Section 7031.5 by any
pP appllrantforaper tsubjectstheapphcanttaaclvllpenslly ofna ..than 4TLETkVTCjLKXTURES
$ five hundred dollarsTS500).
QQQ ❑I,as owner of the property,or my employees with wages as their sole R ENTIN'E ECTR SQ'FT' STORIES'- ! TYPE CONSTRUCTION
compenestlon;wHI dothe work andthe structure brat intended or offeredfor 1
D sale(Sec.7044,Business and Professions Code:The COntactoes License Law +
$
does not apply to an owner of property who builds or Improves thereon,and
whodoe°euchworkhim lfmthr ghM°ownemployen,providedthatstich OCC GROUP RFS.UNITB.
improvemenbmnotintendedorofferedfmsale.IRhowevepthebuiliingor,. TOTAL: -
Improvementl wldwithinoneyearo(compleliogtheowner-bu0derwillhave
@n�rden of paving that he did not build or Improve for purpose of wk.). QTY, PLUMBING ER T " FEE pLOOD ZONE APN '
LJ I,roe owner of the property,am exclusively co,ntracHng with Iicenud PERMIT ISSUANCE
mntractom to mnsWct tM project(Sec.70K Businem ami Professions Cade: -
The Cantrectore Llcenss Law cissa not apply to an owner of Property who N, -DRAIN&VENT-WATER(EA).
Wilds or Improves thereon,and who contracts for such pk0jem with a - FEE SUMMARY
m0iractor(aexemptlicensed.de,'Spursuant to the Contractots License Law. BACK FLOW PROTECT.DEVICE
LLfiI exempt under'Sec. B&.P C for this reawn
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
- Date RECEIPT 01
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX - Y N
❑l hereby a((Irm C I have•certi(late of consent ro sell-insure,ora RECEIPT M
cedl(iale o(Worken'Corripensatlontnsurance oracertifled mpythereo((Sec. ,. GAS EA.SYSTEM-1 INCA OUTLETS, PARK FEE Y N
- 3800,lab CJ '
Polity p - - RECEIPT M .
Com any - GAS EI.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cdified copy is herebyte
Codified ropy b tiled withh the ccity Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
city
CERTIRCATE OF EXEMPTION FROM WORKERS" GREASET'RAP v._ PAID '
INSURANCE
COMPENSATION NCE
(Ifilseectlon need not be completed if N NSURA is feranehundred dollare SEWERSANITARYSTORM EA 200FI Date Recei tin -
(g100)mless') "-' WATER HEATERW/VENT/ELECTR`. ENERGYFEE ' Y • N '-
„ I mdlfythat In the performance ofthewmk forwhich this permit is Wtied, r
I shag not employ any person in any manner an ax to become subject to the , WATER SYSTEM/TREATINT;
Workera'Compensatian Lawaaf California.Date PAID
O Applicant
Z p NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEIN RESIDENTIAL PLMB. SQFT,• Date Recei tg
should become subiect to the Workem'Compessation provblons o(the Labor TOTAL:
V4 Codeyoum.at forthwith complywlthauchprovlsion°orthbpermltshallbe
W j deemed revoked. BUILDING FEE .00- SEISMIC FEE
_a ., CONSTRUCTION is a ON LENDING AGENCY _
Therebyaork for at with thiemrettuctlonkndec. agency 097,Civ.C.)
perform- - TOTAL: ELECTRIC FEE - t
.� 0 anceor.the Namekforwhich thiopermit bissued(Esc.3097,CIv.CJ ' PLUMBING FEE
(� ]enders Name -
LL F Lender's Address QTY.1, MECHANICAL PERMIT FEE MECHANICAL FEE
O W
UI mAifythatl have readthisappliatlonand statethaflheabove information
1 Iscorrect.lagreetocomplywithall cityand counlyordlnancesand state laws PERMIT ISSUANCE FEES PAID: -
�. W relating to building construction,and hereby authorize representativa Of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER'OR ADD TO MECH. Dale Recei f#
.. (We)agree to save,indemnify an d keep harmless the City of Cupertlw - - P
against liabilities, costsand expenses which may In anywayaccrus - AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agam}�+�Id City In cons f the granting of this permit
/r J_1J�"' G��. / �;P7—/4d AIR HANDLING UNIT(OVER 10,000CFM)' CONSTRUCTION..TAX-
Signature o plant/Contractor Data EXHAUST HOOD(W/DUCT) _ CONSTRUCTION'TAXTAID:
HAZARDOUS MATERIALS DISCLOSURE - -
Will the applicant or fuwm building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tM
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the p
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL: (.
❑Yea N No -
Willtheapplicantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)" ISSUANCE DATE ,
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PFI'OR 100,000 BTU). - Pl
r Yes
4havereadthebaza usri Na
materials reqm
uireentsunder Chapler6.95of BOILER-COMP(OVER 100,000 BTU) o
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the Wilding does not currently have a tenant that it Ls my NEWRESIDENTIALMECH. SQ.FT. 2 •��gp '
responsibility to notify the Occupant of the requirements which must be met UN'
prior to issuance ofaate
fCertifiof Occupancy. / 't t
ei4 e (O•`a1-7
Owner ne aadRmlzed agent Date ISSUED BY:
TOTAL:
OFFICE COPY