20610 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildinR Prefect Identification PERMITNO.
^ Building Addreen
,/ 02iV6 20610
e ante: one: A
l'R�1Nn FeDu�UA gC��
01I7 CITY OF CUPERTINO-BUILDING DIVISION
Coamence'aNa�j Lie.N. APPLI TION / PERMIT � [
0-I<.ZV b � gwj-06 CATEGORY CO ROIA\
Architect/Eagiruer. Lk.No: BUfLDINGEL., CAUPLUMB[NGMFLHAMCAL (_CJb
QIYCTR PE FEE BUILDING PERMIT INFO
Add. . rlftTI AN � El El 1:1LICENSED CONTRACTOR'S DECLARATION
Thereby "that l am Bcenud under previsions of Chapter9(commmu C JOB DESCRIPTION
Ingwlth Se t1on70W)of DivIslon3 ofthe BuslncasandProfeulonsCocie,and my
license is In full form and effect.
License Class Lit.g
Date Contractor A
ARCHITECTS DECLARATION 201-IODOAMPS �C G `
p�
NO Zp Iunderstand OVER 1000 AM[5 SQ.FI.FLOOR ARA $M.FT.+ my plans dull be used u public records. p pp ^ pp
S� Licensed Professional SIGNS ELECTRIC
6 jOWNER-BUILDER DECLARATION n
2t, Thereby affirm that[atm exemptfromlhe Contractor's License Law finehe SPECIAL CIRCUIT/MISC
Oo following rcuon.(Section 7031.5,Business and Professions Code:Any city orTEMP.MtiI'IR ORPOLEI
muntywhlchnru
qulapermlttomutrust,alter,Impmve,de=16h,orrepair
anystmmmpriortolbimameaborequbestheappUmntforsuchper ito POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3wۥ DATE
Contractor's License Law(Cha pter9(commencing with Section 7000)of Divi. SWIMMINGPOOL C
O sion3 of the Business and Professions Code)orthat he is exempt thernfromand VALUATION
/s
the basis for the alleged exemption. My violation of Section 70315 by any 6V
�FFF(((pOOO appticant fora permit subOUTLEISSWITCHESFlXlURESjects the appileant to a civil penalty of not rearethan QOS
K!e
five, asrcwnerofthepro NEW RESIDENTIAL ELECTR SQAT. STORl TYPE CONSTRUCTION
❑4 as owner of the property,or my employers with wages an (fere Bole
compensation,willdothe work and the structure boot intended or offered for
p dale(Sec.7044,apply
to an owner
f Property
ons Code:The Contractors rat License law
does not apply torn owner ofproxagh who nemporlmprw provits ded
t thereat,and hat such OCC.CROUP RFS,UNITS
EE whodoeseuchnts amwork tInten edoorthrough his owne.If,h es rare build Ing or
Improvements a add within
the owevegdider, Wlhave TOTAL: _
Improvement bsoldwlthlnansyeuofcomplctWrytheowner-bu0derwillhave
'he burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
ElI,as owner of the property,am exclusively contracting with licensed
cantrscton to mretruct the project(Sec 7044,Business and Prof eslons Code: PERMIT ISSUANCE
The Contractor's License Lew don oat apply to an owner of property who ALTER-DRAIN&VENT-WATER
Wilds or Improves thereon,and who emon ct. for such Inapens with a FEE SUMMARY
e�jB_t[aa (a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. 0&P C for thin muon
Owner Data DRAINS FLOOR ROOF,AAFA,GOND. SANITARY Y_ N=
WORKMAN COMPENSATION DECLARATION RECEIPTa
❑I hereby.(firm that I have•cert fiesta of consent to self-Insure,or FIXTURES PER TRAP SCHOOL TAX Y N
certificate of Workers'Compevauon lnsuranco ora certified copy thereof(Sec. RECEIPT N
3100.Lab GAS EA.SYSI'FM.11NC.4 OUTLETS PARKFEE Y_ N_
Policy I - RECER'I N
GAS EA.SYSfEM-OVER 4(EA)
aey BUILDING DIVISION FF.ES
WCertNed copy is herebytd. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
E]Certified copy b flied withh it.the cid.city Inspection dlvlaton.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SMRM EA 2DOFl• Date Remi t#
(0 e section need nut becompletedl permit pedl later one hundred dollars
(5100orlcu.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that o the person
any
m work an as to b this permit c issued,
I shag not employ any person In any manner at u to become subject to the WATER SYSTEM/TREATING
Wwkere Compenutian Lawn of California. DatePAID
ZZ NOTICApplicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
O Nould beO subjc APPLICANT:If, this Certificate of Exemption,you
Fshould become subject to the Workeri Compensation proviaionsofthe Labor TOTAL:
K W Code,you=atforthwith comply with such provisions or thin permit shall be BUILDING •E
deemed revoked.
LLI CONSTRUCTION LENDING AGENCY SEISMIC FEE
S Iherebya(firmthat there is a construction lending agency for the perform- ELECTRIC FEE
7 2 once of the workfor which this permit b bound(Sax.3097,Civ.C.) TO L
U O Lcrudee.Name PLUMBING FEE
IL F- Lenders Addreu QTY. MECHANICAL PERM(T MECHANICAL FEE
OW Icertilythatlhavereadthisapplicellona.datatethattheanow.mfornutlon
4 bmrrect,]agreeto complywith all ctlyand counlyordinancee and nate laws PERMIT ISSUANCE FEES PAID:
} mcourgm bulldingconsUuctloryand hereby eulhorlu reprnenutivn ofthb -
r
tltytoenterupontheabm
ove-mentioned ppertyfor Wpectbss
npurpes. ALTERORADDTOMECH.
Z
_ (We)agree to save,indemnify and keep hamom the City of Cupertino Date Receipt#
against liabilities,Pdgmenb,costa and expenses which may in anywaya=Ma AIR HANDLING UNIT(TO 10,000 CFM)- SUBTOTAL:
gaunt wid Clty in onsaprence of the gra esti g of tMa permit
AIR FANDur4c DNlf(OVER la,IDecFM) CONSTRUCTIONTAX*
Sigrutureof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSh ERIALS DISCLOSURE
Will the applicant or future buil le.ocacupartstomorlundlchaaardous HEATING UMTOD 100,0001ITU0 Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: r�
RYen No
ill theapplkant or Nrebullding onvpantuseequlperent ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaMruntsas defined by the Bay Am.AU /� R�
�r a la
it Management District? BOILER-COMP OHP OR 100,0(0 BTU) PAMD
I I Yu Q No '
- veread the hazy ons.materials requirement,under Chapter595 of BOTLER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I JUL 1 `1199)
understand that lithe building does not correctly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ17
responsibility to nonny the occupant of the requirements which must be met
prior to Issuance of a Certificate ofOccupa cry. Citi of,Cu �Jp
Owner or authorized agent Date ISSUEDBY: T�
TOTAL:
OFFICE COPY