20895 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'e.t Identification '
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20895 .
wnere ante: one: p p
4 A2 •H C y /q r G / CITY OFCUPER77NOBUILDING DIVISION
pGcorsName: . APPLICATION / PERMITL)
BULDING-ELECTRICAL-PLUMBING MECIUMCAL CATEGORY C
OONT
ROL pJ/L L4 3,`4 3Gr
Architect Eagimer. a Lie.No: . ,..
G _ QTY' tELECTRICPERMIT�t'`I !t, I:FEE "I')".4'BUILDING1 PERMITHINFO
Address: 6 �j e/(',SOA-,Sj
4 ; hLIl
PERMTISSUANCE xly�I
LICENSED CONTRACTOR'S DECLARATION, E � ,E- E
]hereby affirm that l am licensed under provisleas of Chapter 9(commen APPLIANCESRESIDENIAI. JOB DEsCitiPi ION -
ingwlthSe on7000)of Divlalon3o(the Busim andiwif sionsC e,andmy
licenarlsln full rce died, PANELS -
License i� Lk..3
Date L o ^Contractor
ARCHITECTS DECLARATION 701.1000AMPS
p�p�uu a07p ]understand my plam shall be used ae public records. OVER I000AMPS 5Q;FT.FLOOR AREA E/SQ.Ff.
Fi Fj Licensed Professional SIGNS ELECTRICAL l
<< flus OWNER-BULDER DECLARATION SPECIALCIRCUT/MISC
Iherebyaffl.that Is.exempt from the Contractor's Limnee Gw for the ,
pp following reason.(Section 7001.5,Business and Professions Code:Any city or
O y F TGiP.METER OR POLE INST. .. -
F� cauntywhich requires bcomtmct,alter,improve,demolbh,or repair
a a anystructure priorto Its lesuance,abo require the applicant(orsuch permit to POWER DEVICES
O U file a signed statement that he Is Bmmed pursuant to the provisions of the '
3W y Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
t, O.J7 sion3ofthe Businessand Profemlom Code)orthathehaempttherefmmand VALUATION'
tthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCFICSFU(T'URES
O applicant for a permit subjeclathe applicant to a civil penally elect more than
five hundred dollars($5M, NEW RESIDENTIAL ELECTS SQ.FT. STORIES TYPE CONSTRUCTION
�n: ❑I,as owner of the property,or my employees with wages as Iheir sok
compensation,will do the work,and the structure is not intended or offered for
O sale(Sec.7004,Business and Professions Code:The Contractors License law
5 S does not apply to an owner of property who builds or Improves thereon,and OCC.CROU' RIS.UNITS
EE whodcessuchworkhlmselforthroughhlsownemployees,pmvldedthalsuch
improvemenbate not Intended oroffered forsals.ILhowevegthebuildingor TOTAL: -
bnprovemembsoldwithinoneysarofcomplelioktheowner-builderwlll have . -
theIurdenofproving that hedid nabuild orimprove for purpose o(wle.). Q'T'Y. '.' '1.PLUMBING PERMIT,',',",•' .HAODZONE.. APN
LJ L as owner of the property,am exclusively mntnaing with m` - pERMITISSUANCE I'l
contractors to construct the project(Sec.7044,Rualnessand Profeealom Code: l G� '
The Contractors Llmms Law does not apply to an owner a property who '
Wilds or Improves thereon, and who contracts for such PNlecv with a ALTER-DRAIN&VENT-WATER(EM -
��..tlIattot(s)Bernard pursuant to the Contractor's License Law. FEE SUMMARY
LJl am exempt under Sec.' B &P C for this masonBACK FLAW PROTECT.DEVICEOUTSIDE FLLS
Cz
Owner Data DRAINS-FLOOR ROOF,AREA, SANITARY SAMT'ARY Y_ N_
RECEIPT a
WORKMAN COMPENSATION DECLARATION- FD(TURES PER TRA SCHOOLTAX Y_ N_
❑1
he aff rm that I have a certificate of consent to self-Insure,ora ��11 CoRECFRT 0
M00,Lab
Cf)Worken'Compemadonlnauraner oraerrtlfled copythereof(Sec. GAS EA.SYSTEM.I MCA OUILLFS Kx� PARK FEE Y_ N_
RECE]T X
Policy M GAS EA.SYSTEM-OVER 0(EA) -
' Com any � BUILDING DIVISION FEES
�
Cedlfled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECIC FEE
❑Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,700FC. - DBIC RCWI I#
(This wdlon need na be compl&Md If the permit b forone hundmd dollars
" (. (unify that
' WATER HEATER W/VENT/ELECTR 2� ENERGY FEE Y N
Iced 00)or Ites.)t in the performance of the work(orwhlch this permit b issued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING Wcrkere Compensation Lawsof California.Date PAID
-
0 Z Applicant . NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exereption,you
should become subject to the Workers'Compensation provisions of the LaborI Q TOTAL:
N
Code,you=at forthwith comply with such provisions orthb permit shall be �"') BUILDING
EE
LU 9 deemed revoked. - '
CONSTRUCTION LENDING AGENCY SEISMIC PEG
11 I o f thy oro for
w there b a comtmdlon lending agency for the pedortn ELECTRIC FEE
TOTAL:
Z ace of Name
forwhlch this permit is issued(Sec.3097,Civ.C.) \W
LL O L.endice.Addr PLUMBING FEE Oa CD
F lenders Address' QTY, MECHANIGAL'PERMIT,„'' •,•FEE
OW 1cartifythat l have read lhisapplintion and state thauheaboveieformatten MECHANICAL FEE
1 bcorrecl.l agree to complywith all cltyand county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
r relating tobulidingurstmctlon,and herebyamhortm expresentativeso(thio
H N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z Mr)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agAmIllabilitic . dgments,costeand car enact which may In anyw attme AIR HANDLING UNIT 10,000CFM) SUBTOTAL:
gainat ul Nconaequena of antl�g of this rat (/�/ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Sig to App t/Contracto to / EXHAUgTHOOD(w/DUCn CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISC SURE _
'
Will the applicant or future building occupant store or handle hazardoes HEATING UNIT(TO100,000 BTU Date Recei t#
material as defined by the Cupertino Munldpal Code,Chapter 9.1 Z and the -
IlealthandSafetyC Ion 25537(.)7 HEATING UNIT(OVER 100,00)BTU TOTAL: Old
❑ Yea o
'Will the a pphant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whicheMthagamcrtsair
tract? pants as defined by the Bay Area Air - }�p .
Quality Mawgemem qFb-r yN�o BOILER-COMP DIB'OR 100,0(4,BTU) A=AIP'
4Yea �'`O” A sP (j
haveealth&Sfetmode,Seals rcons2555,2553 and 255 .1 of BOILER-COMP(OV172100,000BT1n G 1990
the Californiaunderstand to Health the building
Code, otcuruntlyh 8533andt,that 7 '1
rasp.manfty to if hecsgdoa not currently q.irrocetsave a which
that it boy NEW RESIDFN77ALMECH. SQ.FT. 6 j
- responsibility to notify the occupant of the rcquircmxnts which must he met
prier ceo(a Cc,ifl ate of0 mpa •IQ lea
'� ' City of hlrn!tfnn �'yL.
Owner or aur and agenF w X I Dat F-.Rs }�7�s,s� ��
TOTAL: ISSUED OY:�`� V' -� '—�""V
OFFICE COPY
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