20687 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'ect Identification PERMIT NO.
,Ballding Address: 20687
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one: A
neral are�Lbs: CITY OF CUPC•RTINO-BUR DING DIVISION I G -� Q Q�
c Nam: Lie.No: APPLICATION if ERMIT —`�l �CtJ
—e BUILDING-ELECTRICAL . BIN MECHAMCAL CATEGORY CONTROL
A 1 e / glncer. Lie.No:
QTY ELECTRIC PER,4T FEE BUILDING PERMIT INFO
Address: �v + IMMETISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECOCRATION
I hereby affirm that l am licensed under provisions ofChapter9(commene. APPLIANCESRESIDE L) ]OB ESCRUIFION
Ingwith force anDiviect. o(thc Busincssand PmfesslonsCode,and my n 1l n n 0
license b in full force end effect. PANELS /
0\ 0
LlcenseClass Cort - ,Jy.
Date Contractor NI IOOOAMPS
ARCHIlECTSDECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ON Z I understand my pkv shall be used u public reminds.
=O
Z t, Licensed Prvlesslovi SIGNS ELFG AL
OWNER-BUILDER DECLARATION SPECIAL CIK MLS'C \
f., Ihercbya/firm that am exempt from the Contractor's License law for the
�OF'� following reawnt.(Section 7MIS,Business and Professions Code:Any city or TEMP.METWRPOLE
Fy countywhich rcciatema permit toconstruct,alter,improve,demolish,oreepalr
anystructme prior to its Wearce,alorequlrcs theapplicant fonuch permit to pOWEBD CFS
U file a signed statement that he k licensed pursuant to the provisions of the
Ho'o. Contractors License Law(Chapter 9(mmrrencing with Section 7000)of Divi- SWIr1hINC POOL C VALUATION
Ohm sum3ofthe Business and Pmssl
feonsCode)orthat hole exempt therefromand
Q 5 the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITCHESFIXTURFS
+� O appllcantfora permit subjects the applicant to a civil penalty of not morethzn
p� five hundred dollars(5.500). NEW RESIDENTIAL ELFGTR SQ.FT.
6^� F11,as owner of the property,or my employees with wages as their sok STORIES TYPECONSfRUCTION
C ompensatlon,will d o the work,and the structure Is not Intended or offered for
$ O sale(Sec.7Wk Business and Professions Code:The Contractors License Law
� S does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
5^ whodoessuchwork hlmselforthrough hisownemployees,provided thatsuch
improvement.are not Intended mm fore I tarsals.If,however thebulldug m TOTAL:
improvement Issold within ovyearofcomplebn theowner-buBderwlll have
th�n ardcn of proving that he did not bund or Improve for Purpose ofwle.). QTY, PLUMBING PERMIT FEE FLOODHDNE APN
L-i L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: 1,2,00
The Contractor's License Law does not apply to an owner of Property who ALTER-DRAIN A VENT-WATER(EN
builds or improves thereon, and who contracts for such pm�ojewith a FEE SUMMARY
cqB mm'(s)licensed pursuanttothe Contractor's LicenseLaw. BACK FLOW PROTECT DEVICE
U I am exempt under Sec. B A P C for this reason
DRAINSFLOOK ROOF,AREA,COND. SANITARY Y_ N
•
1v Date Date RECEITa
,net-
COMPENSATION DECLARATION FIXTURF_S PFR TRAP SCHOOL TAX Y_ N_
91 hereby affirm that 1 have a certificate of consent to self-Insure,ora RECEIPT X
,niflate of Workers Compensation Insurance ce a certified mpythercof(Sec. CAS EA.SYSTEM-1 INCAOUTLLTS PARK FEE Y N
3800,1.bC.) RECENT 0
Policy Y GAS EA.SYSTEM.OVER 4(EA)
'Com any BUILDING DI VISION FEES
�CsnIfied copy is hereby furnished. GREASE/1NDUSIR,WASTE INTERCEPTOR PLANCIIECKFEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SKNITARY-STORM EA.pBFT. Date Recei I#
(fhlssection need not be completed If the permit b foram hundred dollars
($IW)orlvas.) WATER BEATER W/VENT/E.ECTR at� ENERGY FEE Y_ N_
I certify that In the perfomunce of the work forwhlch this permit is issued,
I shall not employ any person in any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatlon laws of California.Date PAID
O Z Appliant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
ZO NOTICETO APPLICANT:if,after making this Certificate of Exemption,you
should become subject to the Workeri Compensrons
ation pvisioof the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE
deserted revoked. SEISMIC FEE
WCONSTRUCTION LENDING AGENCY
d Iherebyafflrmthat there isamnstructlon lendlegagency,forthe perform- TOTAL T/ ELECTRIC FEE
M Z ante of the work for which this permit is issued(Sce.309-/,Civ.C.) a PLUMBING FEE BO
(.) 0 lander.Name
MECHANICAL PERMIT FEE
H Lender's Address QTY. MECHANICAL FEE
OO Icertifythatl have read thbappliattonand statethat theabove information
S ismrnx<.l agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building mvWctlon,and hereby authorize rcpersmodNes of thla
U) cit to entero the above-mentiovd roforW i n ALTER ORADDTOMECH. Date Receipt#
~ Y(We)agree save,indemnify an d keep ham inss the ity of C No
V against liabilities,pdgments,mks and expenses which may In anywayacerue AIR HANDLING UNIT CID 10,000 CFM) SUBTOTAL:
against said City In mnsequ once of the granting of this permit.
AIR]iANDWNG UNIT(OVER 10,000 CM) CONSTRUCTION TAX
Signature of Appllant/Contractor Date EXHAUST HOOD IN/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE `
Will the applicant orfutu to building occupant store or hand to hazardous HEATING UNIT(TO 100,030 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 2S532(a)2 HEATING UNIT(OVFR IW,"BTU) - OTAL: I
Yes r]No
Will the applicant or future building occupant use Nulperent or devims VrNfILATION PAN(SINGLE RFSID) 1$$'A CE DATE,
which emit hazardous air contaminants as defined by the Bay Area Air s J 19
Quality Management District? BOILER-COMP OHP OR IW,000 BTU) `
I- t 4 Y . No ROILFR.COMP(OVIR 100,000 BILI
'
have read the hazy ous materials requirements under Chapter 6.95 of 5
the California Health 6c Safety Code,Sections 25505,25S33 and 25534.i
understa ad that if the bu ilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which=at be met Lw•.�.
prior to iss arcs of a Certificate ofOavpany.
A4?00-4 q,/ /o-/S-9Q
Owner or authorized agent VV/ TOTAL:
r Date - ISSUED BY: Ql✓
OFFICE COPY