20689 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERwTNO.
Building Address: ^O 6(�
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wners anp:
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APPLICATION SUUV=A
CITY OF CUPERTINO-BUILDING DIVISION
` Contra .Nene: Lic.N.: APPLICATION / PERMIT �0 -/S 90
—1C1 B�J>-� Lr BUILDING-ELECTRICALPLUMBING-MF HAMCAL CATEGORY CONTROL X
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address/ O .�E R �' 7l) PERMIT ISSUANCE
LIE ❑ ❑ 1:1CNS ED CONTRACTOR'S DATION
Ihereby affirm'hat l am lkmsed under provisions ofChapter9(commenc. APPLIANCESRESIDENTAL ]OLD ON
ingwlth Socion7000)of Division 3ofthe Businessand ProfeskmsCode,and my
license Is In full force and effect. PANELSCAS
License Clan ont0 jolt
r
Date CContractor
ARCHITECTS DECLARATION 201-1000A,MPS
DCO I understand my plans shall be used as public records OVER Im AMPS, SQ.Fr.FLOOR AREA S/SQ.FF.
t] Licensed Professional SIGNSELECTRICAL
6 m� OWNER-BNLDER DECLARATION $pECfAL CIliCU1T/MISCO
2ti Thereby afnrnthat lam exempifromthe Contradorb LlcenwIAwforthe
02 following reason.(Section 7011.5,Business and Professions Code:Any city orc \`
F f't�. county which requires a permit to construct,alterrn
,improve,defish,orrepalr TIAP.M OR LE INST.
��.c any structure priorm its issuance,also requlrestheapplicant for such permit to p, :l ,`i'
file a signed statement that he is Lensed pursuant to the provisions of the t0 DEVICES 1 1
w t; Contractor's License law(Chapter 9(commencing with Section 7000)of Owl. gV,7A MI •G POOL FT.ECIRIC t�
•ion 3 of the Business and Professions Code)or that he he exempt therefromand -- VALUATION
•.t the basis for the alleged exemption. Any violation of Section 7031.5 by any
0 applicant for a permit subjects the applicant to a civil penalty of not nmvthan OUTLETS TCHESFIXEURES�
five hundred dollars($500). NEW AESIDFNTIAL�ELECTR
7 ❑1,as owner of the property,or my employees with wages as Ihetr sok I SQFI'. STORIES TYPE CONSTRUCTION
co
< mpensation,willdotheworlsmdthestru=mu am intendecior offend for
p sale(Sec 7044,Business and Profenbns Code:The Contractors License law 1
t 3$ does not apply to an owner of property who Wilds or improves thereon,and t\ �) ` OCGGROUP RFS.UNITS
whodoessuchworkhimrelf orthrough hisown employees,provided thatsuch
Improvements are not intended oroffered forsak.If,however,thebuilding or TOTAL:
improvement issold withmoneyearofcompletioo,the owner-budderwlll have
the-tiurden of proving that he did not bund or improve for purpose of sale.). CN. PLUMBING PERMIT FEE pPgpp ppNE APN
LJ L as owner of the property,am exclusively contracting with licensed PFRMI.I.ISSUANCE
to construct the project(See.7034,Business and Professions Code: /
oO
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT �A)
Wilds or improves thereon, and who moulds for such pwjects with a
actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B&P C fm this reason
Owner Dau DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
• WORKMAN COMPENSATION DECLARATION RECEIPT=
01 hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES PER TRAP' SCI100L TAX Y N
certificate of Worken'Compeosatim Iruuran.or a certified copy thereof elcc. RECEIPT X
3800,Lab C.) CAS FA.SYSTEM-1 INCA OUTLETS PARK FFP Y_ N
Poll 11
Com any GAEA.SYSTEM-OVER 4(EM RECEITTr
CS cAlfkd copy is hereby fumished. BUILDING DIVISION FEES
❑Certlfled copy is filed with the city inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlsscction need net becompleted if the permit isforonehundred dollars SEWER-SANITARY-SIORM EA.200FT. Date Receipt#
($100)orfWATER HEATER W �S ENERGYFEE Y N
Irtlfy that aat in the performance o(the wkfor which this permit is ismed /VENT/ELECTR, a.D(5
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
should become subim to the Workers'Comperxsatlon provisions of the Labor
~ N Code,you must forthwith comply with such provisions ortht shall be TOTAL:
W > ls permit
deemed revoked. BUI DING FE•
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform // ,�/�
O ance of the work for which this permit is heated C5m.3097,Civ.C.) TOTAL 7 W ELECTRIC FEE
LL Lender's Name PLUMBING FEE pQ
ly F enaer9Aahatl QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read thisapplicatknand t.tethattheabovelnhunutlon
ism ect.I agree to comply with all etyand county ordloarms and state laws PERMIT ISSUANCE FEE-PAID:
} Nrelating to building mnstructim,and hereby authorise representatives of this
Z city to enter u Pon the a1xcw rmntiomd property for inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an d keep baroness the City of Cupertino Date Receipt#
against llabllltkq judgments,mks and expenses which maylnanywayaccrue AIR HANDLINGUNIT(TO 10,000 CFM) SUBTOTAL:
agxlnst said City In—sequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CHN) CONSTRUCTION TAX
Sigwture of App HAZARDOUSor Date EXHAUST HOOD(W/DUCT) CONSTRUCFIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building om pant store or handle haratdous HEATING UNIT CTO 100,000 BM
material.,defined by the Cupertino Municipal Code,Chapter 9.12,and the Date ReCCI f#
Health and Safety Code Section 25532(a)? HGTWG UNIT(OVER 100,000 BTU)
❑Yes MN. TOTAL: I()0
Will the applicant orfuture building oavpant use equipment or devices VENTILATION FAN(SINGLE mutt vRESID) ISSUANCE DATE
en
which t harelous air contaminants as defined by the Bay Area Air
Quality Maragemt District? BOILER-COMP OTE'OR 10,000 BTU)
Yes No
have read the baza on materials requirements under Chapter 6.95 of BOMER-COMP(OVER t00,"BTU) PAID
Glp rtrm.�
the Ulifornia Iiealth&Safety Code,Sections 25505,25533 and 25534.1 Il'g1L1/D
understand that lithe building doesnot currently have a tenant,that it is my NEWRESIDENTIALMECH. 9QFT l 7p
responsibility to notify the occupant of the requirements which must be rret rlr I J V IJ^,l
priortoixua ace of a Cent fiate of Ocm pa ncy. NN yN k�u
�a /o iate ��
Owner or.ulhonD
ud agent Date
TOTAL: ISSUEU BY:
OFFICE COPY