20505 APPLICANT TO FILL IN INFORMATION WITHIN RED LiNES — USE BALL POINT PEN ONLY
Buildin Pro'ect Identification PFJ2MITN0.
Building Address:�C� �� ��� 2 0 5 0 5
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�",9L�vS, �'/�v�� ���'-7?2-� CITY OF CUPERTINO-BUILDING DNISION / C�
con �rs �„�: L��.No: APPLICATION / PERMIT b � ( �
� �� �7�� BUILDINGII.ECIRICALPLUMBINGMECHANICAL CATF�GORY CON'IROL N
Archited/En 'neer: Lic.No:
C3'rt ELECTRIC P�RMTi' FEE BUILDING PERMIT 1NF0
Address: PIItMITISSCTANCE .�Q ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am llcensed under provisions of ChaQter 9(commenc- �'I'LIANCESRESIDENTTA JOB D RIP17 N
ingwithSection7000)ofDivision3oftheBusinessandProfessionsCode,andmy [�'��/ `r ��j'�
license is in full force and effed. 3--00� P�� `•� 1 7
License�la Lic.N 1-
Date� ` , Contrador � � r V`,�t�(" �'P �/1/l(� � �
ARCHIT'ECT'S DECLA ION 201-1000 I'S
OVER 1000 94.Ff.FLOOR AREA 3/94.FI.
�Z I understand my plans shall be used as public recorda �
O
�+z V Licensed Profeasional SIG S ELECTRI
�a� OWNER-BUILDER DECLARATION LCIR /
�.., I hereby affirm that I am exempt from the Contradoi s License Law for the
O��p following reason.(Section 70315,Busineas and Professions Code:My city or OR IN�
z F"W county which requires a permit to construct,alter,improve,demollsh,or repair
� a anystructumpriortoitsissuance,alsorequirestheapplicantforsuchpernritto
PO CES
� U file a signed statement that he is licensed pucsuant to the provisions of the
�u,� Contractor's License Law(Chaptez 9(mmmencing with Section 7000)of Divi- S G` L II.E
30� sion3oftheBusinessandProfessionsCode)orthatheisexempttherefromand VALUATION
�a� the basis for the alleged exemption. Any violation of Section 70315 by any p�,E.i.s HESFT ES �� v � _f /�, /� • a �
�,�� applicant for a permit subjects the applicant to a civil penalty of nd more than �' � Q(1 (/
�o� five hundred dollazs($500). �W g�DENTIAL EL TR SQ.Ff. STO TY['E CONSTRUCTION
z� �I,as owner of the property,or my employees with wages as their sole
compensation,willdo the work,and the atructure is not intended or offered for
�p sale(Sec.7044,Buainess and Professions Code:The Contrador s License Law
r3� dces not app ly to an owner o f property w ho b ui l da or improves t hereon,an d OCC.GROUP RFS.LINITS
� whodcessuchworkhimselforthraughhisownemployees,providedthatsuch
improvements are not intended or offered for sale.If,however,the building or TOT
improvement is sold within one yearof completion,the owner-builderwill have
the�urden of proving that he did not build or improve for purpose of sale.). Q'j'y, PLLTMBING PE1tNIIT ��.' g(,ppD ZANE APN
U�,as owner of the property,am exclusively contracting with Itcensed PERMTT ISSUANCE
contractors to construd the project(Sec.7049„Business and Professions Code:
The Contractoi s License Law does not apply to an owner of property who ALTER-DRA:N&VENf-WATFR(EA)
bullda or improvea thereon,and who mntracts for such p{njects with a FEE SUMMARY
contractor(s)licensed purauant to the Contractor e License Law. BAQC FLOW PROTECT.DEVICE
❑I am exempt under Sec B k P C for this reason
DRAINS FI.00I�,ROOF,AREA,COND. SANITARY Y N
Owner Date R���'1'p
WORKMAN COMPENSATION DECLARATION SQ;OOL TAX Y_ N_
hereby affim�that I have a certificate of consent to aelf-inaurn,or a ��'��1�� ��rr�
certificat�of Workers'Compensarion Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
3800,Lab CJ �pb'7.y.+Q/'p� RECEQ'T N
Policy p � GAS EA.SYSTEM-OVER 4(EA)
Com an ,S4 � BUILDINGDIVISIONFEES
�Certified copy is here furnished. GREP.SE/INDUSIRL WASTE INT'ERCII'T'OR PLANCHECK FEE
�Certified copy is filed with the dty inspedion division. r'�.Z
CERTIFICATE OF E7(EMP'IION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE S�R_S,aM1.nxY_srox�t�n zoo�. Date Recei t�I
(This section need not be completed if the permit is for one hundred dollars
($100)or lessJ �,�,A.���`,"���.j.���.I.R ENERGY FEE Y_ N_
I certify that in the pertormance of the work for which this pecmlt is issued,
I shall not employ any person in any manner so as to become subjed to the WA.I.FR SYSTFM�.IREA.I.ING PAID
Workers'Compensarion Iawa of California.Date
; Z Applicant NEW RFSIDENTTAL PLMB. SQ.FT. Date Recei t#
� � NOTICE TO APPLICANT:If,aker making this Certificate of Fxemption,you
should become avbject to the Workers'Compensation provisions of the Labor TOTAL:
� � Code,you must forthwith mmply with such provisions or this permit shall be BUILDING FEE -��%
u � deemed revoked.
L � CONSTRUCTION LINDING AGENCY SEISMIC FEE
I hereby affirm that there is a mnstrudion lending agency for the perform Tornt: ELECTRIC FEE
� Z ance of the work(or which this permit is issued(Sec.3097,Civ.C.) PLUMBING FEE
� � I.ender's Name
L 1= LendeisAddress QTY. h'IECHANICAL PERMIT �E MECHAIVICAL FEE
' W IcertifythatIhavereadthisapplicationandstatethattheaboveinformation
is corced.I agree to comply with all oty and munty ordinances and state laws 1'ERT'1IT 1SSUANCE FEES PAID:
� N relating to building construction,and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes. ALTFR OR ADD T'O MECH.
zM'e)agree to save,indemnify an d keep harmless the City of Cupertlno Date Receipt#
� against liabillties,judgments,rnsts and expenses which may in anyway accrue �R HANDLING iJNIT(TO 10,000 CFM) SUBTOTAL:
againsts ''Ci in conseque ce ofthe anting ofthis permi� �
AIR HANDLING UMT(OVIIt IO,000c�� CONSTRUCTION TAX
Sig�re of Applirant/Contractor Dat� FXHAUSTHOOD(W/DLJC'n CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HF.4T'ING UMT(TO 100,000 BT[J) Date Recei t#
material as deEined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Sedion 25532(a)? HEATING UMT(OVER 100,000 BTU) TOTAL: ,1-
�Yes �No
Will the applicant or future building occvpant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS�I��' ATE
which emit hazardous air mntaminants as defined by the Bay Area Air
Quality Management D'trict? BOILER-COMP(3HP OR 700,000 BT[J)
❑Yes No !( ��� O� ����
I have read the h ar us materials requirements under Chapter 6.95 of BOILFIZ-COMP(OVER 100,000 BN) v v
the California Health&Safety Code,Sedions 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my ��'�`RESIDENITAL MECH. SQ.Ff �, t
responsibility to natify the occupant of the requ'vements which must be met � Qi Cu�i�p�
prior to' uan a rtificate of pancy.
♦ �� .
i�er or authoriud agent Date I��p gy v j � l ��%('�
TOTAL:
OFFICE COPY