24391 (2) .', APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm."Identification y,t' PERMIT NO -
BuildingAddress: • ,r -
A7ed ,��. . 2,4391
nere ante: hone:
(.L aSS 3 q 7CITY OF CUPERTINO-BUILDING DIVISION / U
cnnt�rJG)nraNa/m/g / y LIc.No ' APPLICATION / PERMIT
BUILDING-ELFCMCA4PLUMBING MECHAMCAL CATEGORY : CONTROL q
-� Architect/Engineer. - Lie No:
_ .ply s•S'I' ELHGTRICPERMPF '` 4�,;%FEE � � ,. BOILDING PERMIT.INFO
- Addrces PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION' -
LE
Ihereafprinthat l am licensed under provisions of Cha er9(oommene- APPLIANCES-RESIDENTIAL '
l>Y P P< JOB DESCRIPTION
kM15ataa10h70 )�o(Divi_ N (the Business(!a•n.d Profeelo Code,and my
"enscbnfuBffeet.
Ci
License
Data P .. _ " Ke T((�t{s.//s' �'v Pa,,I�S JJa���/4••'{{
ns
Contractor Ibb
ARCHITECTS DEC 201-1 PS 120TY; �
Oz: I understand my plans shill be used as public records. FTEMP.M=
MPS " SQ FT.FLOOR AREA + S/SQ.FT.
q� O
. '�•��
Licensed Professional „. CAL
Q OWNER-BUILDER DECLARATION - I
In a C MIIC ' �.
7i..; Ihercby affirm that l am exemptfromlhe ContraRor'aLlmese Law for the '
following reason.(Section 7031.5,Business and Professions Code Any city or
' R OR EIN ^ 1�{' I.J I -
county which requires apermit tomwtruct,siren,Improve,demolish,or repair - �'' � K
4F� a any structure prior to its bmiance,also requires the applicant for such permit to ICES. t,v B •file a signed statement that he is Iloomad pursuant to the provisions of theContractor's License Low(Cha er 9(commencin with Section 7000)of Divi- .B TOOL EL C DATEslon3of the Business and Professions Code)or that he b exempt therefrom and ALUATfON
thbais for the alleged exemption. Any violation of Section 70315 by any `a llcant fora mit subjects thea licant to a civil enal Di nt more than ITGFIESFI%TVR
q five
Per I PP penalty ASO s
five hundred dollars(5500).
I,as owner of the roe NEW RESIDENTIAL ELECTR SQ.FT. STOI TYPE CONSTRUCTION
••(n ❑ property,rty,or my employees with wage,as their sole,
• compensation,will dothe work ancithe structure b not intended or offered for -
Ci sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon,and - OCC.GROUI> RES.,UNTCS
CC whodoesauch work himself orthrough hisownmployeea,provided that such
improvements are not intended orofferedforsalee.If,however,thebuilding or TOTAL:
improvement 3ssoldwithin oneyearofcompletbn,the owner-bullderwill have -
thffrden of proving that he did not build or improve for purpose of sale), Qiy, ' ,r,i .,,�PLUMBINC PERMIT' ;ta'�•FEE`i FLOOD ZONE TPN—
as I,as owner of the property,am exclusively mntracUng with`licensed - - 9
contractors to construct the project(Sec.7644,Business and Professions Code: PERMIT ISSUANCE .V0
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FNN
Wilds or Improves thereon,and who contracts for such ploje t,with a
,Lt(ator(s)bcenwd,pureuant to the Contratore Lkense Law.. - t,;r r .FEE'S[,1MMARY
LII am exempt under Ser.' - B&P C for this reason BACK FLOW PROTECT.DEVICE -
_ OUTS I OF 1:1 ITS
DRAINS-FLOOR ROOF,AREA,LAND. SANITARY Y N
Owner - - Data RECEPT#
WORIGNAN COMPENSATION DECLARATIONFECTURES .�P n^ SCHOOL TA% Y_`N
• ❑I hereby affirm that I have a certificate of consent to'eel(-Insme,or a .W
RECEIPT p
3800,Lab
CJ of Workers'Compewatlon lnsurant ora rerti(led mpythercof(Sec. GAFA.SYSTEM-1 INCA OUTT.EI'S" PARK FEE � Y N "
3500,L - ' S
Cooliryp GAS EA.SYSTEM-OVER - RECER'fp
Cany BUILDING DIVISION FEES
,�Certl(led copy bhercby mrnbMed, r " GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE '
ertihed copy Is filed with the city inspection division., -
CERTIFICATEOFEXEMPTIONFROMWORKERS' - GREASE TRAP PAID . _
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This section need rat be complied tithe permit b forone hundred dollare
($100l - WATER HEATER W/VEN'p/FLECTR ENERGYFEE- Y- N_ ..
larti(y tha[In the performance o([he work(orwhich tNs pertnitbbsued, - ,
I shall not employ any person in any manner so sa to become aubjeci to the WATER SYSTEM/TREATING - -
Workers Compensation Lswa of California.Date PAID ,
O Z Applicant ... FEW RES DEN77AL PLMB. SQF. „ Date Recei t1{ .
Z O, NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
'should become subject to the Worker,'Comperuation pmvlelona ofthe Labor - TOTAL:
Nb Code,you=at forthwith comply with such provtslona orthb permit shall beBU NG 14�
W.] deemed revoked. -
iv
CONSTRUCTION LENDING AGENCY SEISMIC FEE 4
a Iherebyaf(irenthat there lseconstrution lending agency for the perform- ELECTRIC FEE
TOTAL
7Z anceofthework forwhkhthb perMtbbsued(&c.3097,Civ.C) ,`, ��0
ej 4 !.ectasia Name PLUMBING FEE
U. H - Lenders Address `kTY t `� „MECFIANICALiPERIv1IT p'+"' rFEE+° MECHANICAL FEE O
O W lcehifythatlhav ad thiaapplicatlonandstateth5ttheaboveinformatlon
' Is correct.]agree to co mplywitb/andthe
countyordmancesand state laws PERMITISSUANCE• FEES PAID:
>. S relating to building construction, authorizerepresualativei ofth:a .Zcity to enter upon the above-menerty for inspection purpose,. ALTERORADDTOMECH.(We)agree to save,mdemm( harmless the City of Cupertino - Date Receipttl (-�against liabiI ,led nb,cosses which may in anywayaccrue HANDLING UNIT(TO 10,OOOCFM) SUBTOTAL• QVaga,. i o equesceingofthiapemd1 -
• CONSTRUCTION TAX
AIR NDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Data E%FL3 HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle hazardous- HEATING T(TO 100,000 BTU)
mavrialasdefined by the Cupertino Munidp.ICode,Chapter 9.12,and the - _ Date _ Recei tR
Healthand Sa(ety,Cod ciion 25532(.)1 HEATING UNIVER 100,000 BTU) TOTAL:
❑Yes' No '
Will the applicant or mrc no
ant use equlpmen[or devices VEN77LATION PA INGLE REBID) ISSP%NCi IOTE
. : which court hazardous air contaminants as defined by the Bay Area Air - A ,•
Qality Management strict? BOILER-COMP(3HPO 00,0(10 BTU). -
!F�Yes IXo _
have readtheh a, a, smateriab gwrcmentsunderChapter6.95of 8O11.ER-COMP(OVPR100,0 BTU)' , OCT 26 1�
the California health&Safety Code, c Ions 25505,25533 and 25534.1 /J O
understand that lithe building doe otmrrentlyhaveaterangthatitlsmy NEWRESIDFNTIALMECA. SQ.FT .
responaibilityton ifytheoccup l of the requirements which must be met
.prior an of Rlficat f ccupanry. CI IA Ur UUPCI11 U4Q
OwevT or autMindagenr - t- Date - ISSUEDBY: s L
'TO'TAL:
OFFICE COPY