20625 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ' I J4 PERMTN'O.
Bu?ding Address:
C) C 33 LF,4 /R 5LF c:� 20625
am : Froam APPLICA LION SUBMII IALA Ih
P t F'$ N j3pfLCrF_(L X52—Q Cr3 G CITY OF CUPERTINO BUILDING DIVISION 7-0 -9/ 0
cent el.Name: �/+ a / Lic.N. APPLICATION / PERMIT
fL
LGCi BUILDINGS ECTMCA MUMBING-MECHANICAL CATEGORY CONTROL«
Architect/Enginue Lic.Na.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1-1 ❑
LICENSED CONTRACTOR'S DECLARATION
El
I hereby affirm that l am Bcensed under providonsofChapter9(comenere APP11ANCES-RESIDENML JOB DESCKB•HON
ingwith Secalo 7000).!Di Axion3ofthe Businedsand ProfessionsCocie,and my
license id' o and MIM. / 'r— PANELS
Llunse CTefs—L�/ .Lie.« 07 5�Jo G 1'/'Y r4NP�
Dale Contractor 200 ANTS AMPS
ARCHITECT CLAR IU
9
0 O I understand my plans shall be used as public records - OVER IODO AMPS `.Q.FT.FLOOR AREA $/SQ.FT.
Ij Licensed Professional SIGNS ELECTRICAL
6 F OWNER-BUILDER DECLARATION
in
SPECIALCHiCI71T/ML9C
HIhercby afOrm that lam exemptfromthe Cantractorb License Law for the
OG- following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP,MEM OR POLE INST.
cos ny m
which requires permit to construct,alter,tmpmee,demolish,or repair
F any structure prior to its issuance,also requbes the applicant for such permit to POWER DEVICES
Ems)U file a signed statement that he b licensed pursuant to the provisions of the
Contractor's Llceme Law(Chapter9(commencing with Section 7000)of Divi-
0VALUATION
sion 3 ofthe Business and Professions Code)or that he is exempt therefrom and SN.'B.(MING POOL ELECTRIC O,
P y.' the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLE7SSW[TCFiFSFI%TURES 1 /sed d v
applicant for a permit subjects the applicant to a civil penalty of net mom than
c. o R five hundred dollars($500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property, STOW TYPE CONSTRUCTION
p peny,ci he empoureis with r their
kZoffered for
Q compensation,Boametheworkanalies Code:
rehe Cmitended or..Law
9�❑ sale(Sec 7044,Budiruss and Professions Cade:The Contractols Littnse Law
docs not apply to an owner of property who Wilds or improves thereon,and
whodoessuchwork hlmselforthrough hisown employees,provided thatsuch OCCCROUP HIS.UNITS
Improvements are not intended oroffercd for sale.If,however,thebuilding or pl;
Improvement issold within omyearo(compldlontheowner-W ilderwill have
t"nden of proving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT
Lj L as owner of the property,am exclusively contracting with licensed D TANS APN
contractors to construct the pmject(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Comrades License law does not apply to an owner of property who ALM-DRAIN&VENT
-WATER fit
Wilds or Improma ves thereon,and who contracts for such piojwith a FEE SUMMARY
ifccc( P a)licensed pursuant to the Contractor'sLicense Law.am exempt under Sec. B & C for this reason BACK FLOW PROTECT.DEVICE OUTSI DE F17 1:9
Owner Date DRAINS FLOOR ROOF,AREA,WND. SANITARY Y_ N_�
. RECFL'T«
_.—AN COMPENSATION DECLARATION pTKTi1RES PER TRAP SCHOOLTAX Y N
❑1 hereby affirm that[have a certificate of consent to self-Insure,ora RECEIPT«
certificate of Wor)en'Compsuation Insurance or a unified copy themof(Sec. GAS -]INCL OUTLETS PARK FEF Y N
MOO,Lab C.) RECEPI'«
Policy« GAS RA.SYSTEM-0VER d(FA)
Cam any - BUILDING DIVISION FEES
Certified copy is hereby to meshed. GREASE/INDUSBL WASTE INTERCQ'TOR PLANChIECK FEE
Cmifo d copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID .
COMPENSATION INSURANCE SEWFA SANITAAY STORM EA.200Ff. Date a Retmi t#
(This smbn need not be completed if the permit is for one hundred dollars
($10Horlera.) - wnrpx HEATER w/vENT/F1.ECTR ENERGY FEE Y N_
I certify that in the periomunce of thework for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATIRSYSTEM/TREATING
Workers'Compensation lawsof California. Date PAID '
Q Z Applicant NEW RESIDLNIIAL PLMB. SQFT. Date RCcei t#
Z O NOTICE TO APPLICANT. f,after making this Certificate of Exemption,you
should become subject to the Workers Compematlon provisions of the Labor TOTAL:
>' Code,you most forthwith comply with such provtsiora or this permit shall be BUILDING FEE 1
cc _ deemed revoked.'
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Iherebyaffirmthatthereb a mmtruction lending agency for the perform- ELECTRIC FEE
7 Z anre of the work for which this permit is Issued(See 3097,Civ.C.) TOTAL:
02 Lender'.Name PLUMBING FEE
LL F- L ralce.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify thatl have read thisapplicationand statethat theaboveleformation
mea.Iagrotw comply withal)dtyand countyoollnancoand state laws PERMITISS(IANCE FEES PAID.
} W muting to building construction,and hereby authorize representatives of this
(— city to enter u Pon the above-mentioned property for inspection pis rposes. ALTER OR ADD TO MEC'.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
againstsaid City In conseque fibs granting of this permit.
2 l e�` r7,)'6,-9 b A R HAND NG MT(OVER IO,000C MI CONSTRUCTION TAX
Signature.!Ap Bn�cam/Cantrador Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA]ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IDQ000 BTI) Date Rete) t#
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Code ion 25532(.)? - HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑ Yrs iJNo
Will the applicant orfuture building occupant use equipment or devices VENULATION FAN(SINGLE RESID) ISSUANCEDATE
which emit haurdom air contaminants as defined by the Bay Area Air A`
Quality Management District? BOILER-COMP PHP OR 100,000 BTU) ID A IP
4Y s �1,�sNo
have read the h.aAcrus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 10D,000 RTU) U
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not corrimly have a tonanq that 11 Is,my NEW RESIDENTIAL MECH. SQFr.
responsibility to notify the occupant of the mcparemems which at W met
prior to issuancea rtif teo O panty. City of Cpnertina
IRI IV 7—;�- `? `I
I Ownerora t orlredagent Date ISSUED BY: `a'
TOTAL:
OFFICE COPY