19849 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build in Pm'en Identification PEAUT NO.
Building Address: - 1 98 4 9
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E 2 — CITYOFCUPERTIN0.6UILDING DIVISION
Contractor',Name: � L1c.No: APPLICATION /PERMIT
d 4G P[� BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Archite /Engineer. He.N¢
QIv ELECTRIC PERMIT FEE +. BUILDING PERMIT INFO
Address:' djr'( ORKT00_SvI4 Ai
V*WKPPERMTISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPLIANCES RESIDENIAL JOB DESCRIPTION
ingwith Sedtun7000)of hvx]nn3 ofthe Businesiand PmfessionsCode,and my
license 1,in full to.and effect. PANES
LicenseClass C, al�t Lich for '
Date�L�27CHITEC4 7W1�
UP TO 200ANIPS
AACHITECI'SD CLARATION 20I-1000 A.MIaS (a kkb1j0I5:-
0
02 I understand my plans shall be used as public records. OVERMAMPS SQ.FT.FLOOR EA $/SQ.FT.
O
c+z 5 Licensed Professional SIGNS ELECTRICAL
6 6 w OWNER-BUILDER DECLARATION
SPECIAL CIRCNT/M
I„ owing affirm that I am...( edi.e711-5,B from the ContractorsLicense Law for t he
F. countingreason.i tionrmit to orumuctand Professions Code:Any city it .gipMAER OR POLI
anysim which rtottspermiltocoomqui stheaprovgdemoush,or repair
P � any stmcture pdortoib iuuance,ahorequlrea<heapplanl(orsu&1 =t a POWER CES
c.U flue a signed statement that he is licensed pursuant to the provlsloru of the
Oa� Contractor§License Law(Chapter 9(commencing with Section 7000)of Diel- SWRAM1 POOL E C
VALUATION
slon3 of the Businessand ProfessionsCode)orthat heir exempitherefromand
Sn the basis for the alleged exemption. Any violation of Section 7031S by any OUTLE
QQ
El,
for a permit subjects the applicant to a civil penalty of not more than
a C o K five hundred della.($500). SQ STORIES TYPE CONSTRUCTION
pm v. NEW RESID L ELECTR FT.
❑I,as owner of the property,or my employees with wages r offered
sole ,
�Za compStation,wlldothe.and k.andthe structure h ct Cormended License Law
O sale(Sec.apply
Business and Prhfessnns Code:The or impo roes License Law
3 Q whoa not apply to an owner of property who builds or improves thereon,and OCG GROUP RES.UNITS
who
ovdoes
mentsa notintended
ntte f or dedorwgh his own e.If,ho eprovidedthatsuch
improvementsarenot intendedearofc for sale.I(howevegflder the ilI haveding or TOTAL:
Improvement bsold withinoneycarofcompletion,<heowner-bu0derw111 have
t4CiluNen of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMRISSIIANCE
contraction 44,to construct the project(Sec.70Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VEN7WATER(FA)
Wilds or Improves thereon, and who contracts for such pinjin with a - FEE SUMMARY
ro��B3(Tanw(s)Bansed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reasonOUTSIDEFFES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT R
WORKMAN COMPENSATION DECLARATION FIXTURESPERTRAP SCI;OOLTAX Y_ N_
❑I hereby affirm that I have a certfiate of consent to self-inwre,or a ✓. REC=a
ofrtlRateo(Workem'Compematlon Insurance or a certified copythereof(Sec, GASEA. INC0UTLETS PARK= Y N
350Q Lab C.) S .4
RECEIPT N
PolicyX GAS PA.SYSTEh1-0VER 4(FA)
Cany BUILDING DIVISION FEESomECertlOed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�y I
Certified copy b filed with the city inspection division.
II`Y CERTIFICATE OF EKEA4PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.2(DFT. Date RCCCI [#
(Thi,section need nor be completed tithe permit isforone hundred dollars
(SIM)of less.) WATER HEATER w/VENT/ELECTR ENERGYFEE Y N
I permit that In the performance of the work forwhich this pewt is issued, ,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Comns
peation Lawsof California. Date PAID
0 Z, Applicant NEW RESIDFNI3AL PLMB. SQFI'. Date RCtt'I [#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Wurkeri Compensation provisions of the Labor TOTAL:
fq Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
LU G deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat there u a construction lendingagency forthe perform TOTAL: ELECTRIC FEE
M 0 arse of the work for which this permit is issued(See.3097,CIv.C.) —
IenderaNaPLUMBING FEE
LL LL me Lenders Adarersa Cr QTY. MECHANICAL PERMIT . FEE
O W. rt
l aditythat l havemabb"applialionand,fate thattbeabove Information MECHANICAL FEE
a iscor .I agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ N relating to building construction,and hereby authorise representatives of this
F city to enter upon the above-mentlord property for inspection purposes. ALTER OR ADDTO MECH.
? (We)agree to save indemnify an d keep harrnlese the City of Cupertino Date Receipt#
L.I against liabllltlas,%adgments,cossand npenxswhlch mayln anywayaccrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
against,aid City,in conaryuene,of the granting of this permit
w//�, AIR HANDLING UMT(OVER 10,O00 CFM) CONSTRUCTION TAX
Signature of nppliant7tZont.nor ~— s Exruusr HOOD(w/DUCI) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEA TING UNIT(TO 100,00)BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
Health and Safety cme,Synion 2s531(a)7 HEATING UNIT(OVER Iffy"BTU) - TOTAL: a
El Yao1A No
Willtheapplica tune building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �[ CE DATE
which emlt hazardous air coreamimnts as defined by the Bay Area Air �MF�6ja�
Quality Management District? BOILER-COMP OHP OR 100,IX0 BTU)
4YNo
havcn read the Faa�usmaterials requlmmentsunder Chapter 6.95of BORER-COMP(OVER IOO,OWBTU) 199Uthe GThfmia Health&Safety Code,Sen Ions 25505,25533 and 25534.1 f 1
u ndersta rad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.ET.
rnponsibility to notify the oreepant of the requirements which must be met fst�ra sat
prior to issuance of refiat lOmpanry. - #111' sN
-r -�3-�
Owner or authorized age � Date
TOTAL:
OFFICE COPY