20826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: n O O
/d act / v G o
nem26
acre: one: APPLICA IION SUBMIl IALA
CITY OF CUPERTINO-BUILDING DIVISION
con/ n°r,Name: ( LI'c.pNot APPLICATION I PERMIT CC VV
q1 / / / - �1BUILDING-ELECMCALPLUMBING-MECIIAMCAL CATEGORY CONTROL If
Arc ect/Engineer. Lic.Na
QTY ELECTRIC PERMIT. FEE BUILDING PERMIT-INFO -
Address: PERMIT ISSUANCE o0 ❑ 1 - - 1:1 1:1LICENSED CONTRACTOR'S DECLARATION �
I hereby
hsecdo 7000)t Dimi.ilicensed 3.fthe usi r LandP ffe son r9 fixonshode,and c- AI'PUANCESRESIDE L JOB DESCRIPTION
'ngweh in ill force and
effeon3o(the Businessand ProfesslonsCode,and my _
litems islnfue- /and c.I PANELS /�� � /
List J __ / �Lia N�/,f�]�_ l// 11
Date_71 QCantran°rIM W1 W Ahk
ARCHITECTS DECLARATION IDI-1000 AM
7 I understand my plans shall be used as public records. OVER 1 SQ.FI.FLOOR AREA 5/SQ.FL
Wtu O 'AL
U(Gj Licensed Professi 1 SIGNS ory
< OWNER-BUILDER DECLARATION SPECIAL CUIT/
Iherebyaffirmthat lamem"opt from the Contractors License Lawforthe
z O_-° following reason.(Section 7031.5,Business and Professions Code:Any dryer
ir
K z F- truct, ter, TEMP EfT:R L INST.
county chum requires a permit toro o mquir athe applicant
improve, forsuch,or mit to
�� any atructureprtemenonto te issuance,licensdpuritartIorsuchpermltto 1p D
file a signed gatemen[that he U licensed pursuant to the provisions of the
3� Contract°/s License Law(Chapter 9(commencing with Sectimn7000)o(Dtvt- VALUATION
�0� sion3oftheBuslnexuand ProfessionsCod0orthathe Vexempt therefromand N ELECTRIC
Sn^ the basis for the alleged exemption. Any violation of Section 7031.5 by any D.D E.� N�REs �R 1
0� applicant fora permit subjects the applicant to a civil penalty of not more than lr
five hundred do1lars(5500).. REBID ELECTR
.. ❑I,as owner of the property,or my employees with wages as their sole SQ.FL STORIES TYPE CONSTRUCTION
kz compenation,willdothe work and the structure drain bit forT VV
'
p Is(Sec.7064,Businessand Professions Code:The Contranots License Law
4l $ does not applyto an owner of propertywho buildsor improves therron.and OCC.GROUP RFS.UNITS
who docssuchworkM1imaeiforthrough hisownemplayees,provided that such
improvements are not intended oroffered forsale.If,howeveq the building or TOTAL: -
improvementasoldwithinoneyearofcomplepon,theowner-builderwill have ,
thet4urden of proving that he did not build or Improve for purpose ofsakJ. QTY, PLUMBIN PERMIT FEE FLOOD-lDNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7046,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pwjects with a FEE SUMMARY'
m,Lttr,anor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this mason
1 EES
DRAINS FLOOR,ROOF,AREA,GOND. SAMTARY Y N
Owner Date RECEIPT If
WORK MAN COMPENSATION DECLARATION FE(RVRES-PER.IRAP SCI{OOLTAX Y_ N_
F-11 hereby affirm that I have a certi0ote of consent to self-Insure,ora RECEB'T N
mdiftateof Workers'Compemationlnsumncearamrtifiedcopythereof(Sec. GAS EA.SYS[FM-1 INCA OUTLETS PARK FEE Y_ N
3800,Lab Q —
Polity X CAS EA.SYSTEM-0VER 6(EA) RECER'T N
Com any BUILDING DIVISION Fr.CS
Certitied copyR hereby fumished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WOR K ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recel t#
(this section need not be completed if the permit It for one hundred dollars
(SIW)orless.) WATER .I.oy W/vFNr/ELFCTR ENERGY FEE Y_ N
I certify that In the performance of the work forwhich this permit is issu ,
I shall not employ any person to any manner so as to me subject to the WATEtSYSTEM/TREATING
Workers'Coerm taws ofG ia. Date�� PAID
0 Z Applicant PN pFato NEWRESIDENIIALPLMB. SQ.FL Date Reoel t#
Z O NOT10E70 AP�IL�CANT (,after making this Certificate of Exemption,you
should become subjects he Workeri Compemationpmvisiomofthe Labor TOTAL:
W Code,you most forthwith comply with such provisions orthla permit shall be BUILDING ••E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL o Iherebyaffirmthst there R ammtrunton lendingagency forthe perform- - TOTAL: ELECTRIC FEE
:) Z anroofthe work forwhichthis permit 6 Issued(Sec.3097,C1v.C.)
0 O lender's Name' PLUMBING FEE
LL I- .Lenders Address QTY.i MECHANICAL PERMIT FEE-
D O Imnlfymatlhavemadthvappuautionand statethattheaboveinfomoon MECHANICAL FEE
1 ommot.I agmcto comply with all city and county ordinance and date laws ppli ISSUANCE FEES PAID:
} W relating to Wilding construction,and hereby authorize representatives of Nb
I.- city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH. Date RCCCIPI#
_ (We)agree to save,indemnify an d keep harmless the City of Cu pen Ino
agaimthibilltie,wdgmerncos cards.peran,whichmayininyw.yaccrus AIRHANDLINGUMT0010,000CFM) SUBTOTAL:
agarnstsald yin conof granting of this permit AIR HANDUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sr ureofA Aiadt/Contractm -//Dke' d IXHAU5THOOD(W/DICT) CONSTRUCTION TAX PAID:
,y HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous HEATING UNIT(TO 1W,000 BTU) Date ReeelPt#
material as defined by the Cupertino Municipal Cade,Chapter 9.IZ and the -
hfeaithandSafetyCode Senion25532(a)? HEATING UNIT(OVER 100,0WBTU) TOTAL: 1-7. 10
❑Yes M No
Willlheapplimnt or future Wildingmmpantuwequipmentordevices VENTILATION FAN 6INCLE RE9ID) ISSUANCE DATE
which emlt hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP QHP OR 100,0(0 BTU)
[?Y" n( "° JUL 3 01990
have read M1azardOua rrutedals requlrcments under CM1apter 6.95 of BOILER-COMP 100,000 BTU)
the California Health&Safety Code,Sections 25505,5533 and 75534. 1
understand that if the building does not curmntly have a tenant,that it is my NEWRESIDENTIALMECA. SQ.FT.
responsibility to notify the occupant ofthe requirements which must be metr Ir t n
prior.to issuance of a Certificate of Oceipanry. J Q: 1',.
Owner or authotlzed agent DateOTALISSUEDBY: ,
T : —
OFFICE COPY