20458 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
' reB Idle m Yed Identification - PERMIT NO.
Building Addmae: 20458
resist o
e ams: _ A
2'r5• (. �D
2-53—jj7*V3 CITY OF CUPERTINO BUILDING DIVISION T
c°no- '.Name, LIc.N. APPLICATION /PERMIT
( BUILDING-ELFCTMCAI.PLUMBINGMECHANICAL CATEGORY CONTROL 0
Architect/Engimer. Lk No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Add. 7,7 k)i 7CJ e . G , PERMITISSUANCE fR.l ❑ El El
CONTRACTOR'S DECLARATION �Y�•
I Mrebyafftrm that l am licensed under provisions o(Chapter9(comment, APPLIANCFSRESIDENTIAL JOB DFSCRBP770N
IngwlthSection7000)of DTW.lo.3ofthe Buslnemand Pmfe w.Code,andrtry
license le in full orce And effect. /_ PANELS t
License Ch k
LYare
Date C
ARCHH7iCHIrECr TSDECLARATION 00 AMPS O-
XCO Iundentand my place sMBM uaedupubecrecads OVEROVER 1000 AMPS SQ.F7.FLOOR AREA S/SQ.FT.
gQU Licensed Professional SIGNS ELECTRICA
6 OWNER-BUILDER DECLARATION SPECIALCEtCU1T/M
I hereby affirm that l am exempt from the Contractor'.License Law for the -
following reason.(Section 7031.5,Business and Profession.Code:Any city or
Ft:. TEMP.METE4ORPOLE
J c°untyctum,requireia permittocomtmuireathe applicant
any atmdurepater[eltehathe is.lmsed pursuant t the provisor ions tto pOWER VICES
O floe a signed statement that he Is licenced random to the pon 7000) of the
u,y Contractor'sLicense LAW usiresand Prhapterg(mm)orthat hewith
exempttherefof Divi.mand
ion 3o(the Buelneeeand l'rofealom Code)orthat Fele exemptthercfromand SWQwTh9 L VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET'S FI FS
Qappllantfera permit subjects the applicant to a civil penalty of not morethan
five hundred dollan(S500). SQPT, STORIES TYPE CONSTRUCTION
roti,E`u NEW RESID L•LECTR
�n ❑I,as owner of the property,or my employees with wages r their sole
compensation,B.,imethe work endthe s Code:Th not Intended or License
ens offeredfor
O sale(Sec. pply Boninessand f property Code:The Contractors heraceGw
donnot
essuch richtan lfmtropghhisoWilds nemporim proidedthat and OCC.CROUP RFS.UNITS
whodoementsworkhimself edoroffe h dorsal.If,
Improvementsare not Intended earofco for th however, Elderwdingve TOTAL:
Improvement lewdwithin oneyhe did of build
Ice tMe for purpose
of slhave
U4,kurdenwner proving of thepredldna excl orimpmvefacting om license QTy, PLUMBING PERMIT FGfi }7ppp ZONE APN
Lj L as owner of the property,am exclusively ess contracting with IImn.M PERMIT ISSUANCE
mntnct°nto comdruct icene Law
(not
apply
to neoand of police Code:
The Contractor's improves
License Lw does nal apply tc f owner a property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improve thereon,henar and who mntraR. for such pTojeab with a - FEE SUMMARY
cgypactortecenexempte under Snt to the Contractor's Llmnse Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for This reamn
OUTSI DE FEE S
DRAINS FLOOR ROOF,AREA,OOND, SANITARY Y N
• Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION FIJ(TURFSPERTRAP 5CHOOLTAX Y N
❑I hereby affirm that 1 have o Insurance
a c of concent to copy
thereof
ora RECEIPT N
3800dotiLab o(Worken'Comperw-7tlon Wurancemacertlfkd copy thereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N
3800,Cer C- / RECEIPT M
Polity M CAS EA.SYSTEM-OVER 9(EA)
Com any rQL7 BUILDING DIVISION FEES
�Certl(led copy ereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpy Is(IIM with the city hupection division.
CERTIFICATE OF"E'MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MITT. Date Recei tit
(TM1lenction need not M completed lithe permit Is(Drone hundred dollars
($100).,1..) WATER FIFATFBt W/VENT/ELECTR ' ENERGY FEE Y N
I certify that In the perfermanceof the work forwhich this permit Is Issued,
I sha 11 not employ any person In any manner An ae to become subject to the WATER SYSTPM/TREATING
Worker Compen..tlon Laws of Callfornla. Data PAID
z Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date Rece1 t>I
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'CDmperdatlon provisions of the Labor TOTAL:
fq Code,you must fort hwith comply with such provisions or this permit shall beBU LNG FEE
W 9 deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm That there Is a austmoction lending agency for the perform ELECTRIC FEE
Z ana of the workfor which this permit Is Issued(Sec.3097,Civ.CB TOTAL:
V Q Lender.Name PLUMBING FEE
LL H Lander's Addrea QTY. MECHANICAL PERMIT FLE MECHANICAL FEE
OWImrtlfylhatlhavereadthIsappliali ..rultatethattheabovelnfneradon
& Incorrect.Tagree to comply withal)city And countycedlnanm,and state laws PERMIT ISSUANCE FEES PAID.
>. cohereby relating t°building nstmotion,and by authorize repreaenotivee°f this
Z city to enter upon the abovcmentkMad property for Wpedion purposes. ALTER OR ADD TO MECH.— (We)agrm to ave,Indemnify an d keep harmless the City of Gu pert ono Date ReceipHl
against llabllitId,0dgmenta,col.a od expenses which may In any wayacwe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:aAdt City inroneequeux of the gra of this permit. AIR HANDLING UNIT(OVER I O,OBO CFM) CONSTRUCTION TAX
Signature of pplleant/Contractor / Data EXHAUST HOOD(W/DU M CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM
Material..deBmM by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei Hf
Health
Yend Safety Codr{e��-Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: > V
No
Will the appllcant°rfutore building occupant use Nulprosm or devices VEMILATION FAN(SINGLE RFSID) ISSUANCE DATE
Which emit haard...air contaminant,A.defined by the Bay Area Air PAID Iity Management District? BOILER-COMP OHP OR 100,000 OTU) PAID
Yrs No
(t� have read thehazar Duo matcrlall.rcqulrcmenteunderChapter 6,95 of 1101LER-COMP(OVER IW,000 BTU) s3P
the California Health&Safety Cede,Sections 25505,75533 and 2SS34.I l'IY 2 5199
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
rcsponsibllity to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occo pa ocy. ;• nE �� nu
t
Owner or author rad agent Data ISSUED BY:
TOTAL:
OFFICE COPY