20509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification PL MITNO,
Building Addr.v: f'�0 O I�
G \9 .
ra . ante: one:
CITY OF CUPERTINO-BUILDING DIVISION y o
^ic."°: APPLICATION /PERMIT I�`
b �' BtnMNGM ECTMCALPLUMBINr—MECHANICAL CATEGORY CONTROL.X
1 en gineer. Lie Na:
QTY - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address ^ ❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATIO
Ihereby ion7OOO)of Di Bem3ofthesed usiroandPmfe&Mon Code,ammc APPLIANCES-RESIDENTIAL JOB DESCRB'DON
Inense 1,1.fon700f1)ol Dl affect ollhe Bueinsssand Pro(essloneCode,and my
license le In full and affect PANELS
Date6^ V
6 _�LIcM �a3 Zed vl \_L rA,p+
Date G^ 4 96 Contractor UP 9CIA� yp�_
ARCHITECT used
p.ARATION OVER
AMP"'
�p+!aO Zp (understand my plans shall be used uspub0cremrds. OVFRIWOAMPS TQ.FC.FLOOR AREA E/SQ.FT.
E ou( Licensed Prnlessbnsl SIGNSELECTRICAL
«<<1e OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Ihereby affirm that l am exempt from the Contractor's License Lawlor the
F2 following reason.(Section 7811.5,Business and Professions Code:Any city or TEMP METER OR POLRINST.
county which requires a permit to mmvuct,alter,improve,demolish,or repair
$$$Y any structure prior to its issuance,also requires the applicant for such permit to MOWER DEVICES
file a Biped statement that he is licensed pursuant to the provisoes of the
3µ Contnct.e.License law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING IDOL ELECTRIC
SOS slon 3 of the Business and Profmi esCode)orthat he is exempt therefromand - VALUATION
the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWI'ICfff_SFLYEURFS oD
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars 0$500).
❑ SpA I,as owner of the property,or my employees with wages as their sole "E `„ '^L� ' STORIES TYPE CONSTRUCTION
< compensation,willdolhe work and thestructure is not Intended or offered for ( ' J
❑ sale(Sec.70K Bualn....d Profnaioes Code:The Contractor's License Law
$$ don not apply to an owner of property who builds or Improves thereon,and OCC.GROUT' RFS UNITS
who does such work hivvelforthrough Ms own employee,provided that such i
Improvements are not Intended oroffereiforsale.If,however,thebuildsngor ( _
improvement issold within omyearofcompletion,the owner-bu Ilderwill have -
t1Isborden of proving that he did not build or improve for purpose of sale.). QTY, NG PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively mntrading with licensed
contractors to coeslroct the project(Seo 7076,Business and Professions Code: BSJBMITT.SSUANCE
The Contractor's License Law don net apply to an owner d property who
Wilds or improves thereon, and who contracts for such ptojects with a ALTER-DRAIN&VENT-WATER BRA)
coy¢actar(e)licensed pursuant to the Contnctor'a Lkenu law. FEE SUMMARY
LJ I am exempt under,Sec B&P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE FEES
Owner Date RECl31r1'M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SC{OOLTAX Y N
❑I hereby affirm that I Tuve•certificate of consent to eel(-Insure,ora RECEIPT I
certifl1.b C.) orken'Compensatlon Laurance macertl(icd copy thereof(Sec. GAS EA SYSTEM-1 INCA OUTLETS PARK FEE Y N --
38W, ab CJ
RF-CEII'f M
Pollq p GAS RA.SYSTEM-OVER 6(EA)
Com ones BUILDING DIVISION FEES
�CertN copy V hereby fum ahed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
1-7 C°rtlned copy I.filed with the city Inspection division.
Y' CERTIFICATE OF EXEMPTION FROM WORKERS' CREA'SETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date RC i t#
' Rhlaunionneed not becompleted lithe perrtdt Vforonehundred dollars
($10°)°rlees') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance ofthework forwhlch this permit is blued,
I•hall not employ any Person I.any manner so u to become subject to the WATER SYSTEM/TREATING
Worken'Compensadonlawsof Callfomsa.Date PAID
Z Z NOTICETO APPLICANT:ILafter making this Certificate of Exemption,you icant NEW RESIDENTULIaLMB. SQ.Ff. Date RLroei t#
should becons subject to the Worker[Compensation provisions of the Labor TOTAL:
�j
IA Code,you must forthwith comply with such provhlom or this permit hail be U NG C7d
W > deemed revoked.
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ileerebyafflrm that there is acoratrunion lendingagency,forth.performry TOTAL: ELECTRIC FEE
D Z anmofthework forwhlch Nb permit isissued(Sec.3097,CIv.C.)
U O lander'.Name PLUMBING FEE
IL - Lenders Adm... QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 crAdythat l have readthisapplicetionand statethattheabovesnforrnation
6 ismrrect.I agree mcomplywith all city and county ordinance•and gate laws PERMITISSUANCE FEES PAID:
W m1a0ngtobuildingmestructlon,and hereby authorize representativesofthb
H coym enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMELH.
? , (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date RetCipt#
V
against liabilities,pdgnwnts,costsa^d expense.whichouylnanywayamue AIR HANDLING UNIT(TO 10,1100 CFM) SUBTOTAL:
agaWtu Clty in c) uenceo(thegranting dthle pemnit.
2/ I.
(�/1 AIR HANDLING UNIT(OVER I%000CFM) CONSTRUCTION TAX
Sig .o A ca/mtt//Contnnor v l EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applIcant or future building occupant store or hand In hazardous HEATING UNIT(TO 100,000 BID) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Sect 25532(a)? HEATING UNIT(OVER 1W,000 BTU) TOTAL: x)
'Ry.Ves . IJ No
01 the applicant orTuwm building occupant use equipment or devices VENDLATION PAN(SINGLE RESID)' 1$$UA'Ir �TE
which em0 haeardous air=is entrants as dell red by the Bay Area Air
Quality Management District?. BOILER-COMP PHP OR I W,0W BTU) ]j a
Ves F1 No
4haveread the hazardous atedaBrequirements under Chapter 6.95of BOILER-COMP(OV9IW,OWBTU)
17 D
the Celifemia Health&Safety Code,Sections 25505,75573 and 25537. 1
understand that lithe building does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. c-QST.
reaponsiblll w.otifyth pant of the requirements which=at be met
prior to ceofa s teof Ocmpanry.
Own r orlu gl (� ^ Date ISSUED BY: '— V 1 -'V/o-^-t.V
TOTAL:
OFFICE COPY