19841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proic I Identification 7 PERMIT NO.
BuildingAddress:
vilc,— 6 3p 55T��� —Q ND 19841
mere ante//: phone: A
ICUS�JtG{1[aa U`-1�
6ew-1 CITY OF CUPERTINO-BUILDING DIVISION
Co atnr "ante Lic.Nc APPLICATION I PERMIT
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ArcMtect/En r. CA BUILDING-ELECnUCALILUMBING-MECHAMCAL CATEGORY CONTROL It
Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PETUEnssuANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES RESIDENTIAL JOB DFSCRII ON
ingwlthSetion7000)of DiWslon3 ofthe Buslressand ProfesslonsCodGand my
license is in---� 7`� on ra G ( PANELS
License Cl Lic.p l , 1� �
Date Contacto
ARCHITECPS DECLARATION 201-1000AMPS
p7O I understand my plats shall be used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA $/SQ,FT,
ZLicensed Professional SIGNS ELECTRICAL '
6I, OWNER-BUILDER DECLARATION SPECIALCB(CUIT/M
7F' a Iherebyaffl.'hat I am exempt from the Contractor's License Law for the
pO following reason.(Section 7031.5,Business and Pmfemions Code:Any city or
u9 TEMP.METER OR POLE I
F� oamtywhichrequireaper tmcoratruet,alter,4npmve,demollsh,ormpalr
q,� a any structure prior to its Issuance,also requires the applicant for such permit to WL .
4�O F O file a signed statement that he Is licensed pursuant to the provisions of the 7F5, Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
sion3ofthe Butnessand ProfemlomCWe)orthathebexcmpttherefromandVALUA1]ON
Yd•� ted basis for the alleged exemption. Any violation of Se tion 7031.5 by anya--- O
t <5 appliantfora permitsubjetstheappiknottoadvil pensltyofnamorethzn J
a q Q e hundred dollars($500). J
-.Ire I,as owner of the property,or my employees with wages as their sole STORIES rYPECONSTRUCTIONcdm-penmtion,wlll Bothe work and theatruturebnot Intended or offered for
O sale(Sec 7044 Business and Professions Code:The Contractors License law
�52 does not apply to an owner a property who builds or improves thereon,andOCCRIS.IIMI5
whoduessuchworkhimoelforthrough hisownemployess,provided thatsuchGROUP
Improvements are not Intended proffered foraale.If,however,the building or TOTAL:
Improvement b sold within one yearofcompltion,the owner-bullderwill have
Ihp*rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE6TODDTONE
LJ L as owner of the property,am exclusively contracting with licensed APNpp(MIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractor's License Law does oat apply to an owner of property,who AI,ITR-DRAW k VENT.WATER(EA)
Wild.or Improves thereon,and who contracts for such p(ujectn with a
tt r(s)licensed pursuant to the Contrator's License Law. FEE SUMMARY
LII am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSI OF FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT k
hereby afflrm that I have a certificate of consent to self-macre,or a FIXTURES PER TRAP SCHOOL TAX Y N
c i to of Workeri Comperuatimi,and ome ora certified copythemo sec. RFOEPTIf
3 W,Lab C.) GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y_ N
PoRry x W CLx1g9380 RECEIPT a
Com any I -- GAS EA.SYSTEM1OVER 4(EA) BUILDING DIVIS16NF"EES
Citifted copy Is nereby filed
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ertJed copy b(Red with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissetlonneed not becompleted lithe permit bforomhundred dollars SEWER-SANITARY-STORM EA.20017. Date Recei t#
51 I0)or rtifythat
J in - WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icenot thatoy any ersoni an tmanner forwNcbcomertnitbbo the _
I Wool[not employ any person In any manner ro as to become subject to the
Worken'CompensaHon Laws of California. ATER SYSTEM/TREATING. Duce PAID
O Z Applicant
Z O NOTICETOAPPLICANT.11,after malting this Certificate of Exemption,you NEWREADENTIALPLMB. SQ.FT. Date Recei t#
should become svbjcdtothe Workeri Compensation provisib pons of the Labbe Al.
or TO
W Code,you must forthwith comply with such provisions orthert Mall
W m
> deemed revoked. BUILDING FEE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perform- ELECTRIC FEE
M Z once of the work for which this permit le Issued(Sec.3097,Civ.C.) TOTAL:
LL Q Lend eea Name ' PLUMBING FEE (M
LL I<naerandmens QTY. MECHANICAL PERMIT FEE
O W Irnrtltythatlhave readthls apptiationanaaatethattheaboveinform'tion MECHANICAL FEE
a Is correct.(agree to comply with all dtyaM county oNinanusand gate laws [sQtMIT155UANCE PEES PAID:
r W mlatiogtobulldingcomtrution,and herebyauthortm representatives ofthis
I_ Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. '
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReeelPt#
against Ubllitim,Pdgments,cotsand expenses which may In anywayaccrue AIR HANDLING UNIT(T010,"CFM)
aga ust said City In consequence of the granting M this permit. SUBTOTAL:
M R HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S�gwmre of Appllant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
'
Will the app0antor future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the Date Recei t#
Health and Safcty Cod�ion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
Yes
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) j,�$InJry�[YIe
which enhazardous
ut alrcontaminants as defined by the Bay Area Air E DALE
Quality Maragemsent D_is_tt '? BOILER-COMP OR 100,000 BTU)
'?have Yes 6/
rcad thehaze a0miterials
oe,Setions 2merb under Cha pter.1 of BOILER-COMP(OVFRIN,000 BTU) APR 6 69LJ
the Califomb Healthk Softy Code,Sections 25505,21533 and 2Si36.1 fi
understand that if the building does ret currently have a tenant,that It b my NEW RESIDFNIIAL MECH. S'QFI'.
r¢poruibility,to amity the occupant of the requirements which mut be
prlorto lxu ne aCertifkate of parry. Cetyl C,gn9( QI
Ow er ora zed agent p�
TOTAL: ISSUEDBY:� 4`!41�/ ,
OFFICE COPY