20667 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification
Building Address: - - "PEItMITNO.
ae20 66 7 ',
re arae: one:. A .
CITY OF CUPERTINO-BUILDINGDIVISIONqq
Lie,No APPLICATION 'P
PERMIT' — 7Q
aS0 APPLICATION
CA7FCAAY CONTROLR '
Architect/Engineer. . Lk.N. .,
. QTY; ELECTRIC PERMIT FEE BUILDING PERMIT INFO
- - Address _
PERMITISSUANCE ( ❑ ❑ - .❑ a
- - LICENSED CONTRACTOR'S DECLARATION (�
IherebyaHlrm that I am licensed under provliions of Chapter 9(mmmenc APPLIANCESRESIDENTIAL JOB DLSCRNHON
ingwlth Sedlon 7000)0f Dlvisi.3 b(the Buslnew"d ProfessionsCode,and my -
Lko.lion-sislnfugforoe iteffect
ZOOS. V t, PANELS .
Date — Contractor et
ARCHITECT'S DECLARATION 201-]000 AMPS -
00 1understandm lane shad be used.public records OVER1f30 AMPS �$/SQ,ilr.
q�v p p _ _ Y P pu � SQ.FT.7I,OOR AREA
k�(1 Licen dProfeeeiaml - SIGNSELEC7RICAL e
OWNER-BUILDER DECLARATION
Jgp I herebyaffirmthat lamexemPt fromthe Contractor'sLhxnse Lawfrnthe SPECIA IRCUIT/MLSC
ZO Z i. following reason.(Section 70315,B..Ie.and Pro(eafons Code:Any city or - -
�� counlywhichrequbeaa Permlttomrotract,alter,lmpmve,demolleh,orrepair' P•M RPOLE INST. ,
a O' anystmdurepdmt-iw .nee,aborequireatheapphcant(rnsuchpermltto POWEIiD U Ble a signed statement that he N licenced pursuant to the provisions of the
3 Lr, Ominador's License Lew(Chapter9(commencin;with Section 7(XD)o(Dlei- - '
X05 skm3ofthe Busineaand ProfearnloCode)mthath.b.xemPt th¢refromand SV ECTRIC VALUATION
O<
O< the basis for the alleged exemption. Any violation of Section 7031OUTLEe
rethan.5 by any FIXTURES " `
appBcantfon pertNbubjedethe applMant too dull penalty of not mo00
flue hundred dollars(5500). - , I 5•
��G711 ❑F,see owner of the property;or my employee with wages see their Bole NEW RESID AL tI SQFI'. STO F5, TYPE CONSTRUCTION
mmpenaadon,wllldothe work andthea[mdureisnot intended or offered for -
O. Bale(sec.7044,Bushes and Pro(�loa Code:TM Contrador'e Llreese Law
$ does eat apply to an owner of property who builds orlmprovro thereon,and
who tloesauchwarkhimeel(orihraugh hleownemplayeesprovided thatsuch OCC,GROUP RES.UNITS
Improvements are na intended oro(fered(orale.I(,however,thebuiWinger TO -
ImprovemenHesoMwithinoneyearo(cample[bRtheowner-bu0derwill have - -
tl(9�urden ofpmving that he did not build orlmprove for purpose of akJ. QTY, P B RMFEE - -
LJ;see owner of the property,am exclusively contracting with licensed PFRMI.I,I ANCE FLOOD ZONE APN
contractors to mwtmd the project(Sec,704y Bualnese and Profealoa Code:
< The Contredor's Llceae Taw does not apply ro m owner Property who -
bu0da ar'Improve thereon,and who contra cri.for such ptojeds with a 'e AL IN&VENT- ATTR -
cg0ttad (e)Hwnwdpursuantwthe Cmn adm'@Li,n.Liw. FEE SUMMARY
l5I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE,
Owner 1 Date DRAINS FLOOR ROOF,AREA,GOND. JPARK�FEE
NITARY Y_ N
WORKMAN COMPENSATION DECLARATION - RECEIPTa '
ay-ri(I hereby affirm that I have a certifiers of concent to self-insure,ora FIXTURES PER TRAP '' 'CGL TAX Y � N
ceftideate ofWorkera Compereatlon Insurance of a certified copy thereof(Sec. - •RFLERxfR
3800,Lab C,�, I GAS FA.SYSTEM-1 INC.40UTLEI5 _ Y— N_
Poliryp GllGela"7./1/»7^J f' RECoo
Co any r - - GAS EA.SYSTEM-OVER 4(FA)
BUILDING DI VISION FEES
(Certified copy V herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR ANCHECKFEE ,
I Cedl(led ropy b filed with the city Inspedlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
` COMPENSATION INSURANCE'
(This sedlonneed not be completed if the permit V fomes hundred dollars . SEWER-SANITARY-STORM EA,200FF. Date ' Recel [N
(51f3)rn1ea3.. . - WA17iH!-@ATEB W/VENT%ELECTR ENERGYFEE Y N .
Icertify that in the performance ofthework forwhlch this permit is issued, '
I shall not employ any person in any manner so u to become subkd to the -. WATER SYSTEM
Workerd Compensation laws o(CalBornla..Date.. /TREATING' PAID
—
0
Z 'Applicant '
Z 0 NOTICE TO APPLICANT:If,ager makl.g this Certificate of Exemptba,you NEW RESIDENTIAL PLME_SQ}7, Date Recei f#
H N
should become subject to the Workers'Compeaatlon provisions.(the Labor - TOTAL:
Code,youmustlarthwllh comply with such provbkusimthb Permit shall be ILDI •E
] deemed revoked. ' ae
-
a �, _ CONSTRUCTION LENDING AGENCY _ SEISMIC-FEE L�]
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit b issued(Sec,3097,Civ.C.)' TOTAL: '
0O Lender'.Name ` PLUMBING FEE
'
LL: U Lender'sAddress - . QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irertity[hat]havereadthieappBretionaM datethattheabaveln(ornatlon
C Ncoma.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID: '
N relating to building comtvdlon,end h¢rebyauthodze repreantativee ofthis -
1— Z city to enter upon theabove-mentlnaInspection property for pection purposes. ALTERORADDTO MECH, ..
V — (We)agree to ave,indemally an d keep harmless the City of Cupertino Date r - ReCeipHt
against liabilities,judgments,mdsand expenses which may In anywayaccme AIRHANDLINGUNIT(rOI0,000CFM) SUBTOTAL:
against aid City in con ance of the granting of this permit Q
AIR HANDLING UNIT(OVER 10,030 CFM); CONSTRUCTION TAX
Signature Appl(cant/Contractor - Date FxHAusTHooD(W/DUC'D - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appEranl orfuhme building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) DRte Retef 4N
material as defined by the Cupertino Municipal Code,Chapter 9,12,and the
'Health and Safety Coded..25532(.)7' HEATING UNIT(OVER 100,000 BTU)!. -TOTAL•
❑Yes No - - •
Will the applicant orfuture building occupant use equipment cr devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which enut hamrdoue air contaminants as defined by the Bay Area Air'
C i dty Marugcmad Dis d7 r - • . r BOILER-COMP PHP'OR 100,IXD BTU) �'�{Pf�i
4 Yes No . aaarJ
have read Health
8a�ous Cod, a 1..25505,255 3 and
&95 o( ' BOILER-COMP(OVER 100,000 BTU)
the Califounderstand
t Health building
Code, of currently
a tenant and25534.[ 1 ri a
usponsi nd that If the rally heocgdcet not erequir mnts whichthat Rutmet NEW RESIDENTIAL MECH. SQ.FT - 6•. `� r -
p
responsibility I.of a Certificate
occupant of the requirements which must 6e met -
prior to lauance ola CertlMate o(Ottvpanry. -
_(��f f�cv
Own r h nud agent -V Date
TOTAL: ISSUED BY..A
OFFICE COPY '