20169 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldemificatian PERMIT NO,
"°"d'nzi4 St�i-INNm'I r u20169
wners .mc: one:
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/I//j CITY OF CUPERTIN0.BUILDING DIVISION
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Cont doe's Nameefr: Lic.No: m� I
�h�n APPLICATION /PERMIT 9
BUfLDINGE7.ECTRICALPLUMBINGMECHAMCAl CATEGORY CONTROL N
Architect/Engineer.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISS(IANC'E ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby that am licensed provisions ofr9(commncAIILANCESRESIDEMIAL
Ingwthdion7000)ofDvslon3ofths Busne,etandProfeadonsCode,and my JOB DESCRIPTION
license is In lis care effect PAnrf7S
LloenseCla LIC M_ -��
Date Contndor _Q�r}�q)syL�
ARCHITECT'S DECLARATION 201-1000 AM
re 7I understand my plans shall be used as public records. OVER 1000 SQ.FT,FLOOR AREA S/SQ,Fr.
WLicensed professional SIGNS CLEC
< OWNER-BUILDER DECLARATION IAL CIRC
i., Ihereby affirm that l am exempt from Contractors Contrao/s License Law for the U0..ggq3qqcy following reason.(Section 7(DIS,Business and Professions Code:Any city or
Pcocq f'7 county which requires a permit to tstmalter,Improve,demolish,or repair TEk\ME PO INST.
a any structure prior to Its Issuance,also requires the applicant for such permit to
AO file a2M signed statement that he 1s becused pursuant to the provisions of the I'ODEVI
V
mre
Contractor's License Law(Chapter 9(mrncing with Section 7000)of Divi-
t- slon3oftheBeffiessand ProfessionsCode)orthat Nets exempt therefromand L VALUATION
^ the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectstheappliesnttoa civil penaltyofoot morethan OUTLETS ES M'
p, five hundred dollars(3500L
❑I,as owner of the property,or employees with wa es as their mk NEW RES[D L EC STORIES TYPECONSTRUCTION
P a hese
compensation,Business work,Prole the,code: h not Intended or offered.Lair
a O sale(Sec.704d,Business and Pro(mlors Cade:The Contractors Llrove Law
q$� does not apply to an owner of pmperty who Wilds or improves thereon,and OCC,GROUP iUNIS
whodoessuchworkhimselforthrough hisownemployMs,provided thatsuch
Improvements are not Intended oroffered forsak.If,however,thebuilding or TOTAL:
Improvement ove'd withlnoneyearofcompidton,the owner-budderwill have
It�urden of m
Pvingthat he did not Wild or improve forpurpos¢.fine.). QTY, PLUMBING PERMIT FEL FLOODZON ApN
M I,as owner of the property,am exclusively=trading with licensed PEgMff ISSUANCE
coto construct the project(Sec.7046,Business and Professions Code:
The Contractor's License Law don not apply to an owner ed property who ALTER-DRAIN&VENT builds - -
or Improves thereon, and who contracts for such ;mejecta with a WATER(EA)
cgntt am(.)hemsed pursuant to the Contractors License Law. BACK FigWPROTECT.DEVICE
SUMMARY
L�I am exempt under Sec. B&P C,for this reason
•
DRAINS.FLOOR ROOF,AREA,COND, SANITARY Y_ N_OU�EFIES
Owner Date
WORKMAN COMPENSATION DECLARATION RECEI"N
❑I hereby affirm that I have a artifsca &In
te of consent to MIsure,or a F0(IVRFS PER IRA' SCHOOL TAX Y N_
certificate of Worken'ComperoatlonlrouranM or a certified mpythereof(Sec. RECENT N
3800,Lab C.) / GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Voll
RECEIPT N
Com GAS EA.SYSTTM-OVER 4(EA) BUILDING DIV]SION FEES
Khifiedm is herebyth thecity GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
IG'Cetllfied ropy b filed with the city Inspection division.
k"l CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSTORM E.A.200FT Date Recti t#
(fhb session need not becompldM tithe permit V(Drone huntlred dollars
(5100)arfei3 WATERHEATER W/VENT/ELECTR ENERGY FEE Y N
[Mnot that fit the person
Mny of heworkmanner as a to become
permit is c booed,
1 shall not employ any person In any manner m n to become abject to the WATER SYSTEM/TREATING
O Applicantppixons Compensation haws of California.Date PAID
NEW RESIDENTIAL PLMB.
ZQ NOTICEco MPLICtiothe ager rrnkingthLCertiftsationcateof ExcmpteLaIn SQFL Date Receipt
CC shouldbode,yo most(forthwith
the Work en'such proislore orchis permit s lab be TOTAL:
WN Code,you most hwith comply with each provblore orchis permit shall be BUILDING FEE C
> aMmad revoked.
(L G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
7 Z aoce of the workfor which this permit la Issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEB
00 fender's Name PLUMBING FEE
LL F Lenders Addmss QTY. MECHANICAL PERMIT FEE
O W I cert ify that l have read this application and state that the above Information MECHANICAL FEE
a 'concoct.I agreeto complywith all es city and county ordinancand state laws PERMUISSUANCE FEES PAID:
} W relating mbullding construction,and lumbyauthorize mpresentativesofthls
Z city to enter upon the abeveerty
-mentioned propforimpectionpurposie. ALTER ORADDTO MFLH.
(We)agree to save,indemNfy an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,cressardcliperses which may lniuywayacrnre AR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal Id City In consequence of eg carica (this permit.
AR HAn'DUNc UNIT(OVER IB,InocEM) CONSTRUCTION TAX
Sign rco(APpBcant/Contractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMTERIALS DISCLOSURE
Will theappllcant or fuwmbull 3ngoavpantstoreorhandlchanrdous HEATING UNIT(TO 100,000 BID)
material as defined by the Cupertino Municipal Code,Chapter 9.32,and the Date Recel t#
He❑alt,aod Safety Code SLectIgA29Tn(a)7 HEATING UNIT(OVER IOg000 BTU) TOTAL:
Willthezpplicantodoom.bulldingoccupantuseequipment ordevices VENTILATION FAN(SINGLE RE!RD) ISS �A•(E
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dist BOILER-COMP pFIP OR 100,IX0 BTU)
4hYes the o U I �4v_ 1
averda Health
out mode,SetioW25505, 5533undernd 2S5r6.95 of BOILER-COMP(OVER 100,000 BTU) GSr�I V .J
the GlBomu Health&Safety Code,Sections 75505,75533 and 25534.I
understand that lithe building dues not corenlly have a tenant,that it is my nTiWRESIDENTIALMECH. SQ,Fr.
respo itybnotify the occupant of there uiremenls which must be met Clr� of
rltn?fliftfl
Ari lois uance oft Certificate of an
Cyr or aulhorlud agent Date
TOTAL: I ISSUED .
OFFICE COPY