20896 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification IT/ �j vr�s� PERMNO.
Bulldln Add mo; � /1 e GLC ��Y'T'�/ G� f/No iso/ 20896
�volvr. arse: /� one:
MR.�MRS, 611-4p
L 44e C/f/91146, CITY OF CUPERTINO-BUILDING DIVISION
Contactors Na i 1 oNo: APPLICATION / PERMIT O l [
lA/R YyF SGoT7 COd ST. 53 .N. BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL -CATEGORY CONTROL N
Architect/Engineer. Lk.No:
(� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreu: !� nJ O /��� PERMITISSUANCE }� ❑ El ❑
LICENSED CONTRACTOR'S D:CLARATION IPJ
I hereby affbm that l am licensed under provisions of Chapter 9 immanent APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith Section 70W)of Division 3 efthe Buslnemand ProfessionsCole and my
license la in NU to.and does. PANELS 'sem //�� {{{���I
License Class L1cN LIP TO 20OAbUf, / U t l w -Lav /�(pw i
Date Contractor 201 1000 AMPS �/ v•'l / a
ARCHITECTS DECLARATION
0 7 I understand my platy slug co
be used as public rerds OVER 1000 AMPS SQ.Fr.FLOOR AREA E/SQ.Ff.
O
�j Licensed Profnsslor)al SIGNS ELECTRICAL
Q
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
IherebyaffimnthatI am exempt fromthe Contractors License law for the
7_(� 'a fenowing reason.J5 ion 70115,Business and Professions Code:Any city or q'FMP.MEDS OR POLE INST.
04I" a muntywhichrequi apermitiomm"d,alter,impmve,demolbh,ormpalr
<YmrM anystructur,prlortoits Issuance,¢bomquireatheapplicant for uch permit to POWER DEVICES
a K file a signed statement that he is licensed pursuant to the provisions of the
3 u,� Contractor'sLicense Law(Chapter 9(commencing with Section 7")of Divi- SWIMMING POOL ELECTRIC VALUATION
OG sion 3 ofthe Business and Professions Code)orthat he lit exempt therefromand
Qthe basis for the alleged exemption. Any violation of Section 701.5 by any OUILEISSWITCH S-FIXTURES a ®D 00
a`o3 oG5 applicant fora permit subjects the applicant to a civil penalty of no room than
five hundred della.($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES 7YPECONSTRLCTION
7 ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure b not Intended or offered for
nsale(Sec.7044,Business and Professions Code:The Contractors License law
$$ does not apply to an ownerof propertywho bulid.or improves thereon,and OCC.GROUP RFS UNITS
whodoessuchworkhim eB orthmugh Msownemployces,provided that such
Improvements are not Intended oruffered forsale.If,however,thebullding or TOTAL:
Improvement bsold wthnoneyearofcwnpletb theowner-bullderwiil have
the_kurden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bunds or Improves thereon,and who contracts for such p(ojects with a
Cactors)licensed pursuant to the Contractor's License Law. FEE SUMMARY
t I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N—
. Owner Dace RECEIPT
WORKMAN COMPENSATION DECLARATION �.�S PER TRAP SCI IDOL TAX Y_ N_
111 hereby affirm that I have a certificate of consent to self-Inure,ora RECEIPT N
certifiateafWarkeni Compereationlrsuraneora entified copythereof 6ec. GAS EA.SYSTEM-1 WCAOUILETS PARK FEE Y N
3000,Lab C.)
RECD N
Co oilry N GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�any
Certifled copy Is heed with the cit. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
❑Certified copy b flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA NOFT Date RCCCI t#
(This section need not W completed lithe permit is for one hundred dollars
(SIW)or less.) WATER HEATER W/VENT/EI.FCTR ENERGYFEE Y_ N_
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
X Workers'Co�ry�y sion Laws of GTlromla. fie PAID
O Applicant Uf/L1RMtY, SC NEW RESIDENTIAL PLMB. SQJ-T. Date Remi t#
Z O NOTICE TO AI'P�ILICA 'f:If,after making this Certificate,of Exern't
FW should becomesubject to the Workers''Compensation provisions of the Labor TOTAL:
cc Cade,you most forthwith comply with such provisions orthb permit shall be BUILDING _ 00
W deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affitmthzt there is a construction lending agency for the perform ELECTRIC FEE
M Z ance ofthe work for which this permit b isured(Sec.3097,Civ.C3 TOTAL:
02 Larder.Name PLUMBING FEE
LL Lender.Aaaress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certnythat l have read thisapplicationand statethattheabove Information
C Is correct.I agreeto complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
rrelating to building rovtroodon,and hereby authorize representatives ofthb .
I— (A city(.,air,upon the above-mentioned property for inspection purposes. ALTER ORADDTO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Re eipt#
V against llabllhks,judgments costsand expenses which may In anywayamue AIR HANDLING UNIT CTO PION CFM) SUBTOTAL:
agairsbald City in consequenceof thegr Ing thlspermit.
�i � AIRHANDLINGUNIT(OW
VERIO,OCEM) CONSTRUCIONTAX
Slgnatu�ol Applicant/c2Conn'v-acttor"� Dae EXHAUST HOOD"/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applla lit or future building occupant atom or ha M le hazardous HEATING UNIT(TO 100,ODD BMDate Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air PAID
� }T��
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) PAI D
Yet, Q No
hMrere.dthehaza ou.. rodarequlrementsunderChapter6.95of BOILER.COMP(OVER100,000BIM � 11990
the California Health&Safety Code,Sections 25505,25533 and 25534.1 1 U J N
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.17T.
m p.nobillty to natty the occupant of the mclu tements which must be met
prior to Issuance of a Certfilcate of Occupancy. Litt( PF !s r-dirin
Owner or authorized a gent Data TOTAL: ISSUED BY: 'N• JCGf
OFFICE COPY