20790 (2) APPLICANTTO.FILL IN INFORMATION-WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification - + P' TNO. <
ding AddreBuil .- , - 20790 - '
.
G wears are: one: AFFUtoli� A
CITY OF CUPERTIN0.BUILDING DIVISION sem, "U,N 10
" a Le.Ne: APPLICATION /PERMIT / 0.J ry
Itect/En .. BUILDING-ELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL#
glneer. - gIOL Z`(o
Addres,:Zao/fl
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/T
PERMITISSUANCE ❑ ❑ ❑ _ ❑
LIC ENSED CONTRACTOR'S DECLAPATON
Ihereby SkvQormtlutlam 8ce3ofthaunder pmvland Pree.sionr9(commmo APPLIANCES-RESIDENTIAL - JOB DESCRIPTION.
Ingwlth inton7900)o(Divifect. ofthe8ualneeand ProfeaslonaCade,and my -
licen�e is In s deflect. O /-� PANELS r
Llcen ss Lk# -
O O Date Cshalbe used u public rel e. OVER 1000 AMPS - J SQ.Fr.FLOOR AREA $/SQ.FT.
pQ?e4 2 I undere an
E (1
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER.DECLARATION , SPECIAL CIItCUf Wz b 1 herebyaffirmthat l am exempt from the Contractors License raw for the
following teasers.(Secdon 7(315;Business and Profeslons Code:Any city er
i-• TEMP.METEROR ST.
cauntywhich requlresa per tmmtutauct,alteglmpmve,de=l0h,orrepalr
g'
-file
hpermit to RVICE9•
_ Rle a signed statement that he b licensed pursuant to the provis10.of the PO
�fn Contractor's License andProessime(comrrethatheiis Section 7090)o(Dlvi- SWINW G TRIC
sion3o(ihe Business and Prdenloru Cade)orthet hebexempttherefromand jj�7.
VALUATIONthe basis for the alleged exemption. AnyviolationofSection70315byany eapplienntfor a permit subjectsthe applicanito a civil penalty of net more than O11TLE HFSSFI Efive h1,as o nerdolors he pm Ng�y RE51 A I STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employee with wages as their sole
compensation,will do the week and the structure Is,not intended of offered for
On sale(Sec.7044,Business and Professions Cade:The Contractor's License Law
052 52 does not apply to an owner of propertywho Wild..,Improves thereon,and' .. - . OCC.
who does such work himself or through his own employees,provided that such GROUP RFS.UNITS..
improvements are not Intended or offered for sale.If,however,thebuildingw - TOTAL: '
Improvement is sold within one yearofcompletion,the owner-builderwill have
t e rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
1,as owner of the property,am exclusively contracting with licensed - .,
centractoo to co.muct the project(Sec.7044,Business and Professlmn Cade: PERMIT ISSUANCE
The Contractors License Law don net apply to an owner of property who
bu . ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improve themes;and who contracts for p(ojects with a FEE SUMMARY
c actor(s)licensed pursuant to the Constrictor's License Law, BACK FLOW PROTECT.DEVICE '
Lf I am exempt under Sec.'. B&P C for this reeom '
DRAINS FLOOR,ROOF;AREA,COND. SANITARY Y .N
Owner - _Date RECEIPT
WORKMAN I he..cSATION DECLARATION ' FIXTURES PER TRAP - SCHOOL TAX Y_ N_
❑I hereby affirm that I have•certificate of consent to opythesalf�insurr,ora . . .RECEIPT N
certificateo(Warkers'Comperuatlenlvuance ova certified copythereo((Sec. ' GAS EA.SYSTEM-1 INCAoumEl5 PARK FEE Y N rA
3800,Lab CJ
PoI1ry N _ GAS EA.SYSTEM-OVER N(EA) +. RECERPF If
Com n4, o r BUILDING DIVISION FEES
rCmtRled copy is hereby hthe city GREASE/INDUSTRL WASTE INTERCEPTOR. PLANCHECK FEE,
❑Gentled copy is filed hereby
the city inspection division.
CERTIFICATE OF IXB. PTION FROM WORKERS' GREASE TRAP
PAID
COMPENSATION INSURANCE SEWERSANTTARYSTORM EA 2(IOFr Date Recei t#
(Thissectlon need notbecompleted ltheperret bforone hundred dollars ,
($190)wfythad WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work fo as to b co permit cleaned, —
Isbell not employ any person In any manner m e to.aroma subject to the WATER SYSTEM/TREATING - -
Workere Compensation Laws o(Califomla.Data PAID
Z Z . Applicant NEW RESIDENTIAL PCMB. SQ,Ff. Date
mRecei tg. 1
_Z O NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you
should become subject to the Workers'Compereatlon provisions of the Labor - _ TOTAL:
)F0 Cade,you moat forthwith comp)ywlth such provlslom orthls permit shall be
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL 'Iherebyaffirmthat there is a construction lending agency for the perform- ELECTRIC FEE
n Z asim of the work for which this permit is Issued(Sec.3097,Ci¢Q TOTAL:
(„) O Leaders N.
" - PLUMBING FEE.
LL H lender.Address' - QTY. MECHANICAL PERMITFEE MECHANICAL FEE `
O W IartlfythatlhavereadthbappUmH nandrtatethattheabmeNformatlon -
a iscorrect.I agreeto comply with all city and county ordinanm and state laws PERMIT ISSUANCE FEES PAID:
} Nrelati.gtobuildingmuntruction,andh.mbyauthorlaempmwntativeaofthis
(•. Z city to enter upon the above-mentioned property for inspection purpose. ALTERORADDTOMECH. Date ROCPJ tM
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino _ P
against liabilities,judgments,coaand expenses which may In snywayamme AIR HANDLING UNIT(TO 10,W0 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
- AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigruturee(Appuant/Cornracmr' Date ExHAusr HOOD(w/DUCT) CONSTRUCTION TAX,PAID: '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Future building occupant store or handle haeardous. HEATING UNIT(TO 100,000 BTU) - Date ReCej til
material as defined by the Cupertino Municipal Code,Chapter 9.1$.and the
Health❑ and Safety Code��f/N�on 25532(a)7 HEATING UNIT 1W,0008TU) TOTAL:
Will the ariutum Bdog occupantequipment or devices VENTILATION FAN(SINGLE RESID) - Ij`j�J�J�'DATE
which emit hazardous air contaminants as defined by the Bay Area Air
6..�'?W
ality MawgementD t ct7 BOILER-COMP E3HP Oft 100,000 BTU) - [�
Ye No ."IJY
avc read the hazar oua materials requlretrents under Chapter of BOILER-COMP(OVFR 190,000 BTU) .u, i+ (w
the California Health&Safety Cede,Sections 75505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it le my "NEWRESIDENTIALMECH, . SQ.Fr. 0:4..
pp ,y
P. 1 Ityto notify then meant of theruforemen6whichmost be net \iI �I, CIInr.,I ltnO
prior ole once of aCe ate panty. '
d
Uvner author sed ag nt a I55 Zu
TOTAL:
OFFICE COPY