19683 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Proert Identification I'ERMITNO.
Building Addreaa; q
ZZ-6 4� CA2 6r,oJG I
9683
wnera ante: Phone:
rut 2 a- CITY OF CUPERTINO-BUILDING DIVISION
c°ntraanr'n NaLie.Ne: APPLICATION /PERMIT �� l
Aft h IEn neer; A� O BUILDINGELEC7RICALPLUMBINC-MFOHAMCAL CATEGORY CONTROL X
p Gc.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERM17755UANCE ❑ ❑ ❑
LICENSED that ED CONTRACTOR'S DECLARATION
I hereby thSedifflrmthatlam Bcmned under heBuW iovand Pm Chapinr9(commenc APPLIANGESRE4DENML JOB DFSCRR'TION
if...I Section 700D)of DlWalm3ofthe Budnessand Pro(eW onsCode,and m
Iittnxbin I. dd(M. PANELS
LlccnmUc.XUPTO
Dal Contractor
ARCHITECTS DECLARATION 701-I000 AMPS
flQ I understand my pla..hall be used u public recnds. OVER00
10 AMPS SQ.Ff.FLOOR AR $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCU1Tf
�o a IherebyalRrn that l am exempt fromthe Contractor's License lAw for the
OZ following reason.(Section 70315,Business and Professions Code:Any city or HEMP . OR ST.
a countywhichnquiresaperNtW.ro tis d,dteplmprovgdemolbh,orrepair
IX� anystm=mprlortolreinuance,abomquires/heappllcantfonuchpermitto POWER I
C file a signed statement that he is licensed pursuant to the pteviams� of the Cantnctor's License Law(Chapler9(commencing with 7000)of Dlvl- 55YBd L}yE VALUATI(;Na
SOS e1on3oftheBus1nessand Pmf.1mn Code)mthat he bexcmpt lherefromand -
the baste for the alleged exemption. Any violation of Section 7031.5 by any /� O
< applicantfora permit subjects the applicant to a civil penalty of not more than
flue hundred dollars(5500). NEW RESIDENTI ECTR SQFT. STORIES D ECONSTRUCTION
�n
E)1,as owner of the property,or my employees with wages as their sole
compensation,will d o the work and the stncham is not intended or offered for
O sale&c.7044,Business and Pmfesslo.Code:The Contractor's License Law
5� does net apply to an owner of property who builds or improves thermos and OCQGROIIP RFS.UNITSm
whodoesms
euchwarkhielforthrough hi.own employ.,provided that such -
Improveents are not Intended orof(ered forssle.If,however,Ihebuilding or TOTAL:
improvement is sold within one yearof completion,the uwner-bullderwlll have
tlVLtfunden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively contracting with limned
rontncton to construct the project(Sm 7044,Business and Professiom Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilde or improves thereon,and who contracts for such pwieas with a
mpUactor(s)Brensed pursuant to the Contractm'v License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
lJ I am exempt under Sec. B k P C for this neaten
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RFOFR N
M
-1OUTSIDE FEES
WORKAN COMPENSATION DECLARATION PER TRAP SCI 1001,TAX Y
Owner N
[:]I hereby afllrm ve that I haa certificate of consent to -InwFIX'IVRES
re,or• RECEIPT M
certllicatc olWorkera'Compewti°nlnsunnce ora ttrtllkd ropylhereof(Sm. GAS EA.SYSTEM-1 INCAOUTLETS PARKFEE Y N
PdlcyY DINGRECEDIVISION
IV
GAS EA.SYSTQrf-0OVER BUILDING OIVISIONFEEg
co�Certlhed mpy b filed with
hthee city GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is Bled with the city inspection dlvleion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thisaectionneed notbecompldised l(/hepemb menehundreddoilars SEWEWSANITARY SMRM EA.moFT. 'Date Reeei 1p
(510 ramify that
WATER HEATER W/VENT/RLECTR ENERGYFEE Y N
]certify that In any person
1.anf tm mannworker
forwhl be. permit cissued, —
I shall not employ any permn In any manner m ss to berome subject to the WATER SYSTEM/TRFATING
Workers Compensation Laws of California. Date PAID '
Z Z NOplicant
TICE TO APPLICANT:It,after making t his Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei Hf
F0 should become subject to the Workers'Compensation provblons ofthe Labor TOTAL:
N Cade,you at forthwith comply with such provide.m this perrnt.hali be BUILDING •Ofl
deemed revoked.
1 C CONSTRUCTION LENDING AGENCY SEISMIC FEE t
IhercbyafBrm<hatthereba construction lending agency for the perform- - TOTAL: ELECTRIC FEE
D Z an.ofthe workfor which thisperend is haued(See.3097,Civ.C.)
Q O Lender.Name PLUMBING FEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfylhatl have read this epplicauon and patethat lheaboveinformation
1 lammed.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize representatives ofthis
Z city to enter upon the above-mentioMned property for Inspection purposes, ALTERORADDTOMECH. Date Reeei Ip
V — (We)agree to save,Indemnify an d keep haress the City of Cu pen Inca P
against liabilities,judgments,mass ay xpenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
xg set na City lmmnsequenc Tt"9r. 9 permit.
AIR HANDLING UNIT(OVER 10,"CF'M) CONSTRUCTION TAX
Sig
of Applicant/Conrado a IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSjiMATERIALS DISCLOSURE
Ill the applicant orfuture building occupant store or handle hazardous HEATINGUMT(TO100,0001ITU)
'material as defined by the Cupertino Municipal Code,Chapter 933 and the Date Reeei tis
Health and Safety Ccdc,5c"j 6.W33(a)1 HEATING UNIT(OVER 100,000 RM TOTAL: 7. CT
Yes o
Ill the applicant orfutam building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) 1$$ pB®ATE
which emit hazardous air rontampfpM
inanta an defined by the Bay Area Air r
lilyYroManagement D1�trid/ BOILER-COMP OHPOR 100,IXD BTAdT3iSocoiertate tioWaof 601LGR-COMP(OVQt 100000BN)
MAR OO
1990
the California Health&Safety Code,Seaton 25505,75533 and 255X4.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff.
responsibility to not the occupant of the requirements which swat be met Cie! of ri,P"r`1
110
to issuance
an
1 !O panty.
ner or authorized at Date ISSUED BY:� J
TOTAL:
OFFICE COPY