19853 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bulldln Pre'ca
6ullding!{ddress: Identification s.8-9Q 9 7 3, P�TNO.19853
• e�
cors Name: phone: APPLICA VON SURMI I I A
•
S 219CITY OF CUPERTINO-BUILDING DIVISION p
c°
met. Lie. °: a
APPLICATION 1 PERMIT
Architm/En ron S BUTLDING-ELECTRICAI PLUMBINGMECHAMCAL CATEGORY CO
i Lk No:
) QTY ELECTRIC PERMIT �,E BUILDING PERMIT INFO
Address (11`f PERMITISSUANCE ❑ ❑ _ ❑
LICENSED CONTRACTOR'S DECLARATION
IherebyaRbm thatI.1kensedunderpro Wonsof Chapter9(mmmene APPLIANCES-RESIDENTIAL JOB DFSCAR'IION
Ing with Seaton 7000).!Dwo,kot 3ofthe Buelnessand I"Intl...Code,and my
license 1.In full form and died. PANELS .
Limit.Date Clam Llc.p �
Date Contractor UP TO 200 ANIPS
ARCHITECTS DECLARATION 201-IODOAMN
q�q�uu ceO I understand my plans shall be used ss.public records. OVER 1000 AMPS' SQ.Fr.FLOOR S/SQ.Fr.
E'd Licensed Professional SIGNSELEC L
Gin 6' OWNCR-BUILDER DECLARATION SPECIALCIRC M
71.,�� 1hcmby.Mmnthatlamexempt inanition Correctors License Law for the
following reason.(Seaton 7071.5,Business and Professions Code:Any city or
O TEMP.ME EROR' LE INSf.
c°untywhichrequlmsapert tommu d,atter,improve,dertnlbh,orrepalr
anystruau ,priorto Be issuance,alsorequiresthe applicant for such permitto
file a signed statement that he a licensed pomuant to the provisions of the
3a"y Contractors License law(Chapter 9(commencing with Section 7000)of Divi- NG F %
OS e]on 3 of the Business and Prufeaslom Code)orthat he is exempt therefromandCT'a SVAWVALUATION
Sr' the basis for the alleged exemption. Any violation of Section 7071.5 by any 011ila ES )
appu.ntf.r.permit.biedstheapplicanitoadWlpemltyofnmmmthan
five hundred dollars(5500. W R FN7iA I (/
�n ❑I,as owner of the property,or my employees with wages as their sole �' TYPE CONSTRUCTION
C < compe...den,will do the work and ilm troaum Is not Intended or offered for
55.. O .1.(Sec.7044,Business and Profenl.ru Cade:The Contractors License Law
F55$ does not apply to an owner of property who Wilds or improvesthereory and OCCGROUI' AFS.AMTS
EE who docssuch work himself orthe.ugh his own employees,.rwWed thatsuch
Improvement..re nauntended or.ffered fm esla.1f however the W llding or TOTAL:
Improvement h sold within omysarofc.mplctbrythe owner-W ilderwlll have
th[jOwrden of provingthat he did not Wild orimprove for purpose ofuk.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LIJ L A.courser of the property,am exclusively mntnaing with licensed ppRMn•1SSUANCE
contractors to construct the pm)ect(Sec 7044,Business and Profession.Code:
The Contractor's Llcerue Lew does not apply to an owner of property who ALTER-DRAIN kVENTWATER tEA)
Wads or Improves thereon,and who contracts for -for such (.jewith a FEE SUMMARY
91)4'.dor(.)licensed pursuant to the Centimeter's License Law. gAIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FITS
Owner • Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
WORKMAN CO dPFN. ITOF DECLAR ION R��p
QI hereby affirm that I have a m Matte.f consent to self-inwre,or a �lURF_S'PER TRAP SCHOOL TAX Y_ N_
adifluteof W.rkere'Compenalionlmumnmmacertif] copy thereof(See. RECEB'TM
3800,Lab C.) GAS EA.SYSI'EM.1 INCAOUTLEfS PARK FEE Y_ N_
P.liry I _ RECEIl'T M
CoAS F.A..SYSTEM.OVER 4(PA)
BUILDING DIVISION FEESffCnrtiOedeopybhembyfumished.
CREIN
ASE/ DUSMLWASTEINTERCEPTOR PLANCHECK FEE
MCertRled copy le(Bed with the city Inspection division. pp
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE land PAIyI/
COMPENSATION INSURANCE
(Thi..ectionneed not be completed B the permit b SEWER SANRARY for one hundred dollars STORM EA.200FT. ate Recei t#
($100)orlcesJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify that in the performance.(the work(orwhkhthb pertNtis4wed, —. —
1 shall not employ any person In any nanner so v to become subject to the WATER gl,RIM/TREATING .
Workers'Compensation Law.of California.Date PAID
-
Z
Z
Applicant
_ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFr. Date Aecei t#
should become subject to the Workera'Compenztton provisions of the Labor TOTAL:
N Code,you at forthwith comply with..&provision or this parrot shall be
W j dremed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d G IhembyafOrmthat there b a maswaion lendiogagency forthe perform- ELECTRIC FEE
0 an..ftbc work forwhichthis permit is inaued(Sec.3097,CN.C.) TOTAL:
Ienderb Name PLUMBING FEE
LL F Lenders Addm.. QTY. MECHANICAL PERMIT FEE MECHANICAL IEE
OW I cedifylhat l have read thlsapplicationand atamthattheaboveinfornation
S Ia correct.Iagree to comply with all city and county ordinances and date law. PERMIT ISSUANCE FEES PAID:
>- 0' to building construction,and hereby authorize representatives ofthls
Fcity to enter upon the above-mentioned ove- entioned pmpeny for Inspection purpose.. ALTERORADDTOMECH.
(0 Date ReCei t#
Z (We)agree to save, mi
indemnify an d keep haresa the City of Cupertino P
against liabilities,judgments costsand expenses which may In any wayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agalnt said City in ansryuence of the granting of this permit.
AIR HANDLING UNIT(OVER 1B,aooCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXFIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.rfuture building occupant store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t# �
materlal as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑WY. No
W the applicant or one building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) - ISSUANCE DATE
whichemithamalou.al contaminants as defined by the Bay Area Air
Quality Management Mal BOILER-COMP OHPOR 100,010 BTU)
4Yes o
havercadthehaza odymaterials requirement.under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) J 1990
the Gllf.rnia Health&Saf Code,Sectiora25505,75533 and 25534.1 tr 1 '• J
understand that lithe building does not comently have a tenant,that it is my NEW RESIDENTIAL MECH. SQPT. I j.l'i s
ropomibllity,to notify the occupant of the requirements which moat be met '
priorlolusuanceofaCertlficaleof Occu anry. Ito
net or aut orbed ag Data ISSUED gY:,5,1`'a�
TOTAL:
OFFICE COPY