20080 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - - - PERMIT NO.
Building Address:
Ades s � .ate . 20080.
came: ane: IA A
Tim /l/fl/i/GY• I09,0.y CITY OF.CUPERTINO-BUILDING DIVISION
C. trid0(8Nd LIc.No: APPLICATION / PERMIT
,� L �I� N UL D IC RY C
BUILDINGELECTRICALPLUMB7NGMECHAMCAL
Lk.Na
„
!" �{�E�:LECTRIC PERMIT� .^ '( �'' , , . '` -BUIGDING=,PERMITrINF '
' '.;FEG'j,''
Address: PERMITISSUANCE
PLUMB lxlt�fl
LICENSED CONTRACTOR'S DECLARATION
Ihthc dion7Ohatlam BcenuftheBuprovisions ndPmfe awsr9de,ind o- AI'PLIANCESIffSTDEN7IAL ]OB DESCRIPTION
Inensa i.ealon7000)ofd efelon3o11he Bustnessand Professions Code,and my -
11<ense le In full f and effect. ._. PANELS V
l.lcensc CIaLk.N /F F
Date_ Contractor
ARCHITECT' .0 TON - 701-I01MAMPS..
q�qf&u�IXO O I understand my pian shall be used ae public record.. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
6 Licensed Professional SIGNS ELECTRICAL _
6 OWNER-BUILDER DECLARATION
Ihercbya(llrmthat lam exempt from the Contractor's License law for the SPECLILCR(CUIT/MISC
,
o p following reason.(Section 70315,Business and Professions Code:Any city or
:Ma), , county which requires a permit tomnstauct,alter,improve,demolbh,oreepair T�P.METLR Oft POLE INST.
117a anystrvtlure prlorto its Issuance,also requlresthe applicant forauch permit to POWERD
D V file a signed statement that M b licensed pursuant to the provislmu of the
3µG Commctofs License Law(Chapter 9(coemarnmg with Section 7000)of DTvl- SWIM NG ELG C
VALUATION
6
1-•�O� slon3uf1he0usinesaend ProfessloraCode)orthet he la.xemptthcrefromantl ,X the basis for the alleged exemption. Any violation of Se tion 70315 by any t-y
applicant for a permit subjectsthe applicant too civil penalty of not more than OUTLE Fl - // OfCIO 1
flue hung ed mare,
the pro NEW RFSI - AL SQFI', a 'STORIES `/ TYPE CONSTRUCTION
�I,eoon,w of the property,mithemmture Is Hintersith ed as their
redfa
compensation,will clothe work andthe structure la no[Intended or offered for
Hit .1.(See.70K Business and Professions Code:The Contractote License law
r R does not apply to an owner of property who builds or Improve thereon,and ,
µ3... OCC.CROf1P RFS.UNITS
w prove a nts am khlmse dee orough Neownle.IE I des,provided that such .
.
Improvements are not Intended oro(feredfor nale.If,however,thebuilding or TOTAL:
improvementlrovingithlnoneyc notImild.riogtheowner-buildA I. have _
t�.�urdeno(provingthat he did not build or lmprovefor purposeafeakJ. "i! ,,'PL B P ITi,'ii:at{` ''t"FEEL• FIORD ZONE - APN
LJ 1,as owner of the property,am exclusively contracting with licensed Q)Mff 1 pN E
contractors to commad the projea(Sec.7074,Susiness and Professions Code: '
The Contrscto11
r's License Law doe na apply to an owner of property who �.�-D -WA (EA) _
Wild.or Improve.thereon, and who omdratle for such projects with a r �FEE;$UMMARY
c tactor(s)licensed pursuant to the Contractor's License Law. (.'
qB.[ .. .. ... .. ..... ..
LJ I am exempt limier See B k P C for this mason BACK FLAW R T.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N.
Owner - - Date RECFII?'1'N
WORK MAN COMPENSATION DECLARATION FECIVREi PER TRAP SCIiCOL TAX Y_ N—
certificate
hereby affirm that 1 have o Insurance
of consent to op thereof
ora RECEIPTS
certittateolWorken'Compensatlonlmurance oracertifled copy thereof(Sec. CAS IA.SYSTEM-1 LICA OU7LLTS PARK FTT Y N
Polic lab CJ
Polity p GAS FA.SYSTEM-OVER 4(FA) DING DI N
' Com any BUILDING DIVISION[Certified copy,b filed tumle city CREASE/INDIJMLWAS'IEINTERCITPTOR PLANCHECK FEE
Certified copybfiled'with the city lropMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
PAID '('JfIT{ ICpn/('�/�
COMPENSATION INSURANCE SEWER-SAMTARY-STORM IIA.X10F 1'. r)
(This section need not be completed lithe permit b for one hundred dollars
($100)or less.) .t WATER HEATER W/VENT/ELPOTR ENERGY FEE Y N
I rertify,that io the performance of the work for which this permit Is Issued,
I shall not employ any permit to any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensalim Ews
aof Celifarnb. Date PAID
Z NOTICE TO APPLICANT:If,after making t his Certificate of liemption,you licant NEW RESIDENTIAL PLMB' SQ'FT' Date Recel t#
should become subject to the Workers Compensat Ion provlalaru of the Labor TOTAL:
N Cade,you most forthwith comply with such provisions orthis permit shall be
> deemed revokes. B ��
~ ILDING •f7'O
W ',
CONSTRUCTION LENDING AGENCY - � SEISMIC FEE
O
S Iherebyaffirmthattherebacensunctlon[endingagencyfortheperform, ELECTRIC FEE ems_
M Z arca.ftha work forwhich this permit is Issued(Sec.3097,CIv.C.) TOTAL" Q
(� O I.ender'.Name UMBING FEE
LL 1— Lenaer'e nadreaa QTY. ." MECHANICAL PERMIT c
OW Icad'fythat I have read this application and statethatthe above Information - EGHANIGAL FEE
C boosted.l agree to comply with all city and county ordinancea and pate laws PERMITISSUANCE L•ES PAID: .
'�. W relating robulldingcomtrualon,and hembyauthorlurepresentative.ofthla -
F Z city to enter theab e-martionedprope forlsapeetionpurposes. ALTER ORADDTO MECH. ..
_ (We)agr save acmNfy an d ke armless the City of Cupertino Date ROCCIp[#
agalnstlla I s,p menta,costsands ns which may In anyway amus AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:aga Lute ityl ro..spenmof sating*&this permit.
_ AIR HANDLING UNIT(OVER I0,000CM) CONSTRUCTION TAX
Sig ure of Appllant/Cortmetor Date EXHAUSTHOOD(W/DUCT) 0NSTRUCTION TAX PAID:'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stomor handle hazardous HEATING UNIT(TO 100,000 BTU) Date RBCCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I lealth�
Yea No
Safety Code,SerctNloon 25537(a)7 HEATING UNIT(OVER 100,000 BT(1) -M
TOTAL:
the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air mntaminanta as defined by the Bay Area Alr
Quality Management District? BOILER-COMP(3IfP OR 100,010 BTU) •'
1 4 Yes No •���
havereaathe icalth car out materials
action 25505, 5533underand 25534.
of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sealers 25505,5533 and 25534. I
understand that it lify the occupant not emquire ants which thatb met NEW RESIDENTIAL MECH. -�.Fr.
responsibility 1.cedaCtheiateof ofthercqulrement.which most be met
prior to Issuance ofd Certifkate of Ocdvpanry. '
Of
inn
Owner or authorized agent Dace - ISSUED BY:
TOTAL.:
OFFICE COPY