19934 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: - 1 9.93.4
41-0-5'3q O ,UGIT?EE
r. - phone: p p
GVT NiC�O S 7 - CITY OF CUPERTINO-BUILDING DIVISION -Z.Z_Lj•h
Contractors lName: n Lie.No: APPLICATION'/ PERMIT
ClA k✓-1ITCR 30026 BU)LDINC—MFCnUCALPLUMBING-MMIMMCAL CATEGORY CONTROL#
ArcMeet/Engineer. Lie.No:
,,.. II ` QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addms: 3 W /%ll,Vf�T �.� PEFMTISSUANCE I(p�g1
LICENSED CONTRALTO SDBCLARATION � 'd--'
I hereby affirentinat l am licensed under pro W.s of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
imgwlth Se i..7000)of Mi .ion3aflhe Buslnemand PmfesslonsCode,andm
licenseblassA fes (e Lill ♦ PANELS
Date Class t��(ZLlap tr / / 111I�YCT``L�'1`L
Date Contractor '
ARCHITECT'S DECLARATION201-IODOAMPS
�7 I understand my piarusballbe used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.,
mO
Licensed Professional GNSELECTI
- OWNER-BUILDER DECLARATION S IALCIRCUIT
Ihercbyafllrm that l sort exempt from the Contractors License Law for the
following reason.(SeLion 7031 S,Business and Professions Code:Any city or ,METRO LE INST.
R countywh(chmqulmsapem twcomtmd,alteglmpmve,demolbh,ormpair
' < anystm=mpdortotb anceaisorequimtheappBantforsuch permit to PO D
c.O file a signed statement that he b licensed pursuant to the pmv= of the
Ow Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Dl vi- VALUATION
sion3o(theBus mandPo slomCode)orthathebaem thercfromand SIPS LELE C
5 the balls for the alleged exemption. Any violation of Section 7a 1S by any O � ES
Q applicant(ora permit subjetathe applicant to a civil penalty a not more than
F C"u five hundred dollars($500). - NEW R D LELECTR
!¢ ❑I,as owner of the property,or my employees with wages as their soli �'�' STOW IS TYPE CONSIRIX;i'ION
Co
mIennation,wBldothe work andthestruaum is net intended or offered for
Cole(Sec.7044,Business and Professions Cade:The Contractor's Liam Law ,
does not apply to anowner of property who builds or Improves thereon,and
cs^ who doessuchworkhimeelforthrwgh hisown employees,provided that such QCCGROUP RES.UNITS
Improvements are not Intended oroffered for sale.If,however,theWilding or - TOTAL:
Improvement's. Mwithinancycarofcompidlogthe owner-bulklerwillhave
thr4rrdeet of proving that he did not build or Improve for purpose of ule.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(See.7044,Bovines and Professions Code: PERMIT ISSUANCE
The Contractor'.License Law does me apply to an owner of property who tALTER-DRAIN k VENT-WATER(EN 6e�^
Wilds or Improves thereon, and who contracts for such ptojes with a FEE SUMMARY
Worts)licensed pursuant to the Contractors License Law., BACK FLOW PROTECT.DEVICE
151 am exempt under See B A P C for thin reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Purser - t Date RECEIPT-
WORKMAN COMPENSATION DECLARATION t
❑I hereby affirm that I have a certltia[e of consent to self-Insure, FIX7lIRFS PER TRAP SCHOOLTAX Y N
or RECEIPT#
certificate of Workers'Compernatlon Insurance ora addled copythefeot fSec. GAS FA.SYSTEM-1 WCAOIITLM- PARK FEE Y N
3800.Lab C.) RECEIPT#
Ccliry# GAS EA.SYSTEM-OVER 4 MA)
Com any tlU1LDINC DI VISIONiTiI's
6C- ertifed copy Is hereby N method. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI"IECK FEE
❑ H
CeBed copy Is filed with the city inspection division'
CERTIFICATE OF EXEMPTION FROM WORK HRS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANRARY STORM EA 2WFT Date Remi t#
fThI,.aI on need not be completed If the permit Is forces hundred dollars
($l W)or less) - WATER HEATER W/VENT/R TRr/e�qq ENERGY FEE Y• N
,. I artily that in the performance of the work for which this permit is bsaed, 21�-T1
1 shall not employ any person In any manner so as to become subject to the WATER SYSI'Qd/TREATIN'G PAID
Workers Compenutlon Law.of Calltornb. Date
D MZ Applicant NEW RESIDrNMAL"B. SQ t r. Date Remi 1p
Z O NOTICE TO APPLICANT.H,aNer nuking this Certificate of Exemption,you
should become subject to the WorkesComperetatlon provisions of the Labor TOTAL:
cc C°de,you moat forthwith comply with such provisions or thGperent shall be BUILDING
FEE
W > dMmed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby affirm that theb a construction lending agency for the perform TOTAL: � pp� ELECTRIC FEE
Z
....(the work for which this permit b Issued(Sec.3097,Civ.C.) �"Is
V O Lender',N. PLUMBING FEE sC�
LL H Lemder'.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedifythallhavemdthbapphutionandelatethattheabovelnfom tion
bcormt.Igreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} IL N Wro
relatingWlldingvtadion,and herebyamhodad
aerepresenve,oftbis -
VZ acity to enter upon the abovcmentlomdl property for Wpe Hon purposes. ALTER ORADDTO MECH. Date RC[CIP[k Z (We)agree to love,Indemnify an d kap harmless,harmlethe City of Cupertino AIR HANDLING UNIT CTO 10,000 CFM)
against itabilltim,judgmrantn,cod.and expenses which may In anywayaccme SUBTOTAL:
againstloiciCityi mnaryuence o(tM grant got thin permit
AIRHANDunc uNrr(OVER lO,000cFM) CONSTRUCTION TAX
,csitISturc° Applicant/Contractor C.1 o(11AUBT HDOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSE E _
Willtheapplica rat or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date RCCfi Ik
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I leallh and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (L-ttt
C]Yes . M No
Will the applicant or future building occupant useequlponat ordeviees VENDLATIONFAN(SINGLE RESIU) ISSUANCE DATE
QuichyManagement altrict? arab as de0md by the Bay Area Air
Quality Management airco7 BOILER-COMP O1NOR I00,0(q BTU)
Yea n No
Th,rve reacithcha,randous m teriahmqutmm nNunderChapler6.95°f BOILER-COMP(OVER I00,OW BTU)
the California Iie.lth h Safety Code,Sectom 25505,25533 and 25511. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.17.
responsibility to notify the oaupant of the requirements which must be met
prior to loan e,fa Ccrtitiala Occupancy. A11aC
me r authonud agent Dae/ ISSUED py;.T�.�2 Lomax lrtsvn y ./rll"''
TOTAL: V�— Q1o✓VL-�^�'�
OFFICE COPY