20427 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Bpllc ng Add mss: /"t O A /�1�
O o t N� G 4 G I
I w r U ^✓ICi� ane. CITY OF CUPERTINO-BUILDING DIVISION rI;—
Contractors Nane: r / _ Lk.No: APPLICATION / PERMIT 1.
ALk.Nm UI
BLDINGELFCnUCALPLUMBING-MECtiAMCAL CATEGORY CONTROL 4
rchitM/En[�}neer.
e ri G h 'QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. QZI �GLU�cnG PE.FMITISSUANCE ❑ ❑ ❑
is a LICENSED CON TRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commene- CES-RESIDENrHAL JOB DISCRB'TTON
ingwith Sc on7000)of Dlvhlan3ofthe Businessand Profes.lonsCode,and my
liz MM
cense is In luB! and ef(e t. PA
' LIcen�Lic Y S___-�C
Date Cantraator h
ARCHITECT'S DECLARATION 201-10011/W'S/ MVI I understand my plans shall be used as public records. OVENIVqAMPS V SQ.FT.FLOOR AREA g/SQ.FT.
O
E Licensed Professional SIG EC CAL
Lr'IA OWNER-BUILDBR DECLARATION C T/
2� a Thereby a(Rrmthatlamezempt lromthe Contractorb Llcenselawforthe1
following reason.(Section 7011:5,Business and Professions Code:An cior
Ff' county which requinsia perMttocorutrucy alter,Improve,demolish,orrepalr ' .M O IN
anystmuc pdortolbh ancgaLwmquritheappBmntrorsuchperMna WERD
O file a signed statement that he h llrensed pursuant to the provisions or the
yy RaI- Contractor's License Law(Chapter9(mmmendngwith5ect1on7000)ofDlvl-
O e1.n3-flh.Buelnessand ProfewWns Code)orthathehe..pttherc(romand ?` LELECTRIC VALUATION
O5 the basis for the alleged exemption. Any violation of Section 7011,5 by any OUT'L SW[TCHESFLKIUREs 000 �•
app0ont fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEWRESIDENTIALELECTR
�n ❑1,as owner of the property,or my employees with wages as their sok SQ.FI'. SCOWES TYPE CONSTRUCTION
compensation,will do the work,and thealrocture is not intended or offered for
O sale(Sec 7644,Business and Professions Code:The Contractor.License Law
S does not apply to an owner of property who builds or improves themon,and OCO CROUIB RES.UNITS
EEEE whod. suahworkhi tforthraughhlsownemployees,providedthatauch
improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement hsold within oneyear.(completion,the owner-budderwlll have
t"men of proving that he did not bu6a or improve for purpose of sal..). QTY, PLUMBING PERMIT FEE FLOOD ZONE ApN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
conmact.m to construct the project(Sec.7644,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)builds or Improves thereon, and who contracts for such pto)ecta with a
ogR((actor(s)Bwnaed pursuant to the Contractors License Law. ' FEE SUMMARY
4 LJ I am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE OUTSIDE FEUS
f DRAINS-FLOG SANITARY Y_ N_
Owner Date R ROOF,AREA,COND. RECEIPT R
WORKMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a certificate of consent W.elf-IsureFO(71lRES PER?RAP SCHOOL TAX Y N
n
,or RECEIPT M
certlRceteo(Worken'Compensatlooloomince or a certllkd copy thereof pec. GAS EA.SYSTEM-1 INCd OUTLETS
3800,Lab C.) PARK FEE Y_ N
Policy 11 GAS -OVEA4(EA) RECMPT#
Cam say_ R UIL DING DI VI SION FEES
❑pcertlrled cut I)-h hereby famished.
❑Certlfled copy 6filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY
(Thlssecti.n need not becompleted lithe permit hlorora hundred dollars STORM EA.200Pf. Date Remi t#
($100)or lass.) WATER EIFATFR w/VENT/ELECTR ENERGY FEE Y N
I certify that In the perlormanceof thew.rk(orwhlch this permit is laved, —
I shall not employ any Person In any manner so as m become..)a.to the WATER SYSTEM/TREATING
Workers'Compensation Laws or California.Date PAID
O Z Applicant Dale Recri tp
Z G NOTICETO APPLICAN.ILafler making this Certificate of Exempllon,you new RESIDENIIAL PLMB. SQFF,
should become mbject to the Workers'C.mpensatlon provhima of the Labor TOTAL:
N Code,you most forthwith comply with such provhlom orthh permit shall be BU N
j M,deeated revoked. G FEE
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirmthat rwhic t iaermwctlsn lending agenryfor the perform, ELECTRIC FEE
� Z ante of the work for which this permit is issued(sec.3097,CIv.C.) TOTAL: _
02 Lenders Name PLUMBING FEE
LL I— Lender.Address QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
O W Icedifythatlhavert.dthi.appBcetionandstatethattheabovelnformatlw
lscorrect.I agree to complywilh all cityand county ordinances and state laws PERMIT ISSUANCE FEESPAI D:
>. 0. misting to building construction,and hereby authomos representatives of this
1— Z city to enter upon the above-mentioned property for impaction purposes. ALTERORADDTOMECH.
(We)agree to save,indemNfy an d keep harmless the City of Cupertino Date Reeel of
V against liabilities,tidgmants,casm.rad expenses which may In any mysomm AIR HANDLING(IMT(to 10,000 CFM) SUBTOTAL:'— t
against said City In consequence of the granting or this permit.
AIR HA NDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature or Applicant/Contractor Data EXEIAUST HOOD(W/DUC'D CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous HEATING UNIT(TO 100,00)BM Daft Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and SafetyCode Section 25532(a)? HEATING UNIT(OVER 100,000 BM TOTAL:
❑Yes ' rj No
WBl lhezpplicant or future building occupant..equipment or device VENTILATION PAN(SINGLE RISID) ] A $DATE
which emit harardous air contaminants as dented by the Bay Area Air r1[�
Quality Management District? BOILER-COMPOHIOR100,o00BTU) IJJV
qYcs f—I No V
Iave read the heza ousmateriah requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) NY
.California health&Safety Code,Sections 25505,25533 and 25534,I
dnicratarad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. .a
n .mpmedbili onMfytheocaupant.(the requirement.which must be met GitY .C11110"Inn
priorto issupfca orqfi teofOccupanry. Y,y Ut
thorised.gen Data
TOTAL:
OFFICE COPY