20669 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add mss: -
106-r 20669
, ova
nen ame: .n.: APPLICA
CITY OF CUPERTINO-BUILDING DIVISION
°^hARe •"•^Y1
Lie."°: APPLICATION / PERMIT
BUfLDINGF3-ECTRICAL-PLUMBING-MECHAMCAL CATEGOry CONTROL N
Architect/Engineer. Li,No:
'QTY " ELECTRICPERMTTPEE BUILDING'PERMITINFO
Address::
Dater� r�
LICENSED
CCON
TRACTOR'S DECLARATION
PERMIT
ISSUANCE
T herebythat amlkensedprovisionsofChenc- APPLIANCES-RESIDENTIAL ENTIAL
Ing with Section
7E00)of Division 3 ofthe
Busineseard ProfeedionsCode,and my IL��
JOB DESCRIPTION
DESCRITION
licenseis infiulgfocWeffect. PANELS
Llmnr CloseOrLic.#mduactor
❑
d
ARCHITECTS DECLARATION 2(11-1000AMIP5
e 2 I understand my plans shall be used as public re card.. OVER 1000 AMPS SQ.FT.FLOOR AR
0 S/SQ,FT,
q O
kU0 Licensed Professional SIGNS ELECTRICALNIX
'
OWNER-BUILDER DECLARATION SPECIALCI(C M
ZF, 7a Ihereby afRrmthat l am exempt froethe Contractor's License law for the
following reason.(Section 70715,Business and Pmfesslons Code:Any city or
emntywhichrequiresapemdttommtmd,alter,lmpmve,de=llsh,orrepalr TFMP.MEfQRO Sf
anystmetum prlorto its issuance,alsomqulresthe applicant for such permitto POWER DEVICES
Q U Ne a signed statement that he b licensed pursuant to the provisions of the
a Contras o'.License Law(Chapter 9(commencing with Section 7000)of Divl-
�0 slon3 of the Business and Professlme,Code).,that he is exempt therefromand S GPOOL VALUATION
the balls for the alleged exemption. Any violation of Section 7031.5 by any
< applicant fora permit subjeR•theapplicaxt to a civil penalty duct encrethan OUTLE WTTC FI
OA five hundred dollars(SSM,
n I,as owner of the property,or my employees with wages as their ante NEW RM ELL FE STORIES TYPE CONSTRUCTION
compensation,will doth°work andthestactum b not Intended or offered for -
sale net
apply Business end f property
Code:The C.ntadors Deme Law
$$ whodotisuch toan.wner ofdpropgh hisonempWilds orimproovidednes re.,and OCC.GROUP RFS.UNITS
whoove eats am
mrn t int a intended
orough hlsownemp,hove provided that such
Improvements arenot Intendedearofred(.sale.ILhowever,ilder illhave TOTAL:
Improvement(sanldwitM1ln oneycarotcompldion,rhe owner.bullderwlll have ..
tl,,ifurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively mntractlng with licensed PERMIT ISSUANCE
contactors to mnskuct the project(Sec.7016,Business and Professions Code:
The Contractor's License law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who redirects for such pSojeR•with e
ryaLfactor(e)licensed pursuant to the Contractors License Law. BAIX FLOW PROTECT.DEVICE 'FEE SUMMARY
Lj I am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N
,• Date RECEIPT'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
I hereby affbm that I have o l...e of consent m ay-themo a a REC IPI N
art Ocate.fWorkesa Compewtloniwuranaaaekl(led copy thereo'I&,.
3800,Lab C.) CAS EA.SYSTEM-]INC.60UTLETS PARK FEE Y N
Policy If Q/e.Ve lq /��Q� - RECEIPT#
Com an T� GAS EA.SYSTEM-OVERd(FA)
r c/Nsn ( BUILDING DI VISION VE ES
Cedi d mpy is bercbytumecity GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy V(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFT Date Remi tM
(this eedl.n need net M<omplded If tM permit V(Drone hundreddollars
(5100ftifyss3 WATER HEATER W/VENT/ELICTR ENERGYFEE Y N
I certify that o tan performance dime work for s tob ibis pesrnit is booed, —
1 shat nor employ any Laws in any manner an u to become sub)ett to the WATER SYSTEM/TREATING
Workera'C.mpensatlon Laws of California. Date PAID
O Z Applicant Date Recei ted
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.IT.
should become subject to the Workers''Compersatlon provisionsof the Labor TOTAL:
N Cod,you at forthwith comply withsuch provsimea orthb permit shalt be
j Bernard revoked.
BUILDING d C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirenthat there Is a construction lending agency for the perform-
antELECTRIC FEE
Z e ofthe work for which this permit b Issued(Sce.3097,Civ.C.) TOTAL:
U O Iander.Name PLUMBING FEE
IL f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
O W I certltythat I have madthls app11cationand at.mthattbeabove information
Iscorrect.I agree to comply with all cltyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Y C relating to building construction,and hereby authorlu representatives of this
Zcity to enter upon theaWvcnentiosed property for Inspection purpose. ALTER OR ADD TO MECH. Date Reeei ted
— (We)agree to save,Indemnify an d keep harmless the Clty of Cupedlno P
agaimtllabllitles,indgments,m&•andexpenseswhkhmaylnanywayaccrue AIR DANDLING UNIT(TO 10p0O CFM) SUBTOTAL:
agai t said City In ands yuenggggyf the gr ing of Ods permit.
/—",o AIR HANDENG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI roan Applicant/Contrador /Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thcappllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) . Date Recef ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Fiealth and Safely Cod�dion M32(a)7 HEATING UNIT(OVER 100,000 BTU!) ,,,b
Yes N. wAt_
Ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) . ISSUAN EDATE
which emit harardousairco taminantsasele0sud bythe Bay Area Air 8 1990
. Quall'tyMasugement s7 BoaER-COMPprRPOR100,0(UBTIn AUG
'PhYea No
ave read the Nazar cue materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,0°0 BII1)
the Glife mial Health&Safety Code,Sections 25505,25S33 and 25536. I r1IDn1',IRf1
understand that ifthe bullding does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. City (If
responsibility to notify the occupant of the requirements which must be,net
prlorfeslssuanm°faCedifkateo ecu R 4 n
Owner or authorized agent Date - ISSUED BY:
TOTAL: -
OFFICE COPY