20562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addma: G
�I S (o C) ZE'N ck jv,) L`J 2
0562
A AL DAM
01 r26 L' Q�y Zy'3- S-7) CITY OF CUPERTINO-BUILDINGDIVISION
• Contra ',Nan.: Lie.No: APPLICATION / PERMIT lD L
Mjj A" - W BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL it
ArcM1ite</Engineer. 1 Lie.Na:
aI / QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: f Z�) t/V/n S4- !S PERhITI55UANCE `� El El ❑
LICENSED CONTRACTOR'S DECLARATION L�]
I hereby affirm that l am licensed under proentiont of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPDON
Ingwlth Scctbn7000)of Dwh.mr 3ofthe Businessand ProfenionsCode,and my
licence b In full(o�JCa end died. ! PANELS
WcenscChn_Lz��_Lle.M
Date_44jFz ._Contranor�h
ARCHITECTS DECLARATION'S MI.100DAMA
se I understand my plans shall be usad as public records. OVER IODD ASQ.FT.FLOOR AREA $/SQ.FT.
O
x d of Licensed Professional SIGNS ELEC
<Zw OWNER-BUILDER DECLARATION SPECIA IR
t- 'Lp IhcrcbyalRrmthatlam exempt from the Contractor's License Law for the
pO W following reason.(Section 7031.5,Business and Professions Code:Any dry or
KZF'.I countywhich requiersa permit reconstruct,alter,improve,demolish,compair TEM(P.M.aoanystmmm prantoltsissuance,alsorequires theappbrant forsuch permit tof O lU file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVaContractor's Lbeve Law(Chapter9(commencmgwithSection7000)ofDivi-
Osion 3 ofthe Business and PrefesslonsCode)orthat he le exemptthere(romand SWIMMIN VALUATION
•-t the basis for the alleged exemption. Any violation of Section 7631.5 by any OIE7SICHSXTUFapplicant(orapermitsubjatheapplicanttoacivilpenaltydnotmrmtfom --2-0
QO
�w five hundred dollars($500.
❑1,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR �.FI'. SfOWPS TYI'ECONSTRUCT'ION
�6 compensation,wll do the work,and the structure ti not intended or offered for
,a O sale(Sec.7WJ,Bosbess and Profemlons Code:The Contractors License Law
5 �R does not apply to an owner a property who builds or Improves thereon,and
who does such work himself orthrough his own employees,provided that such OCC.GROUIr R ES UNITS
improvements are not intended or offered for sale.If,howevcq the build ing or TOTAL:
Improvement World within oneyearofcompletlon,the owner-Wilderwill have
th rden of proving that he did not build or improve for purpose ofnle.). Qyy. PLUMBING PERMIT FEE FLOODZONE APN
Li 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontracton to on.trod the project(Sec.7044,Busmen ami aior
Prefen Code:
The Contractor's License law does not apply to an owner of property who
WildsALTER-DRAIN&VENT-WATER(EA)
or Improves thereon,and who contracts for such p(ojects with a
C¢tt ve
actors)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this man
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMAN
EES
Owner Date
WORKMAN COMPENSATIONR��,0 DECLARATION FLYTIRF_S PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that 1 have o Insurance
ate of consent to op theme,ora RECEPT p
cediflLathC.Workera'Compematlon lruurana ora certified copy thereo((Sec. GAS EA.SYSTEM4 INCA OUTLETS PARK PER Y N
38110,Lab CJ
Policy p—(cJ ( 7 GAS LA.SYSTEM-OVER 4(EA) RECEIPT If
Com any 7 - JI�IA BUILDING DIVISION FEES
Certified copy b herebyfurnished.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
er Uted copy Is filed with the city Inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SE VERSANITARYSTORMEA IOOFT Date Recei t#
(IMctio
ssen need nu be complMed If the permit is!Drone hundred dollars
(Sl N)mrlen.) WATERHEATERW/VENT/ELECTR ENERGYFEE Y N
Iart1(ythat mthe pedomuna of the work forwNch this permit is lowed, N—
I shall not employ any person In any manner n se to become wbject to the WATER SYSTEM/TRG,DNC
Worker'Compensation Laws of California.Date PAID
O Applicant
Z NOTCETOAI'PLICANT:IL raker making this Certlflate o(Exemption,you NEW RESIDENTIAL FEAR. SQXT. Date Recei t#
should become subject to the Workers'Compnr,satlon provblons ofthe Labor TOTAL:
4k Code,you=at forthwith comply with such provulonsorthe,permit shall be BUILDING 'E Sat CD
deemed revoked.
LU
GCONSTRUCTION LENDING AGENCY SEISMIC FEE I
I hereby affirm that there V a rorutmetion lending agency for the perform,
M Z znce of the work for which this permit b Issued(Sec.3097,CW.Q TOTAL: ELECTRIC FEE
O O lender:Name PLUMBING FEE
LL 1= Lender's Addren QTY. MECHANICAL PERMIT FEE
O W Icedlfylhatlhavemadthbappliatlonandstatethattheabovelnformation MECHANICAL FEE
0. Is correct.I agree tocomplywith all city and county ordinances and state laws PERMIT ISSUANCE FEESPAID:
Y W relating to building concoction,and hereby authorize representatives ofthb
U) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,pdgments,mansard expenses which may in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
�o//
against said City in consequence of the granting of this permit. �
fes ` OMRHANDUNGUMf(OVER10,O3OCF I CONSTRUCTION TAX
Signature of Ap ant/Contractor Dae EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappli"morfuture building occupant store or handle hazardous HEATING UNIT(TO IDgU)
000 BT
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Recel t#
I lealth and Safety Cade Section 75532(a)7
❑Yes NN. HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous air coram rat
cam as cleared by the Bay Area Air
0Q.a lity Management District? BOILER-COMP DEE'OR 100,"BTU)
Yce gI'�No
have read the hazar`Tous materials requimments under Cha peer 6.95 of BOILER-OOMP(OVER 100,000 BTU) UN
understand the California Health&SafetyCode,Sections 75505,75533 and I5534.1 s.J U, 2 i99Q
understand that lfthe building does not corrently have a tenant,that it is my NEW RESIDENTIAL MECH.
mrreSQ.FT.
responsibility to notify the ocropant of the requirements which=at be t
prior to issuance of a Certificate of Coups ncy. nftia of C
Owner or authortred agent Dale TOTAL: ISSUEDBY.^'D•�i�t UVJ
OFFICE COPY