20899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification _ PERMIT NO.
Builday -1- 2 /_ I r � � - � 20899
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nera one:
Te.e CITY OF CUPERTINOLBUILDING DIVISION
Contractors Name ,� �� ue.Nd: APPLICATION /PERMIT d—
BUILDING-ELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL M
Archtted/Engineer. Lk.Na:
QTY ELECTRIC P/6417,' FEE BUILDING PERMIT INFO
Address: ;Z OG s r PERMITISSUANCE 13 J,L�i FLUME MECH
' LICENSED CONTRACTOR'S DECLA IONEl E
I hereby affirmthat l am licensed under provisions of Chapter9(commenc. APPIJANCES.REMDENDAL I JOB DESCRIPTION
Ingwlth Sedion 7000)of Dlvision3ofthe Businessand ProfessionsCode,and my
license is In fuIfRIce and effect. (lP
LicenO c.0
Dae ANF75 "�'�` '`^'�.^ I ��^•7
ARCHITECTS DECLARATI45N 7014000 AMPS
RMZO
UI understand my plsru shall be used as public records. - OVERIOOOAMPS 1 .Ff RAREA $/SQ:FT.
rE Licensed Professional SIGNS ELECTRI L .
<�<N' OWNER-BUILDER DECLARATION SPECL1LCItCUI I -
IhembyaffirmthatI am exempt from the Contractor's License Law for the
Al
following reason.(Section 70315,Business and professions Code:Any city orMETER O E
cauntywhich requlresa perrNttocomtre ct,alter,improve,demolish,orrepalr
q'y anystrudure prlarto its Issuance,also requlrestheappllcant forsuch perndtto DE'VI 5
'i, E5 r4 Bk a signed statement that he is licensed pursuant to the provisions of the
0Qy O p., Contractor's License Taw(Chapter 9(commencing with Section 7000)of Divi-
go,I fthe
ivi-
go,Iofthe Business and Professb,Code)orthat he is exempt therefromand "NIj IODLELE C � VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any se_-- '
appbcanlforapermitsubje theappllcanttoa civil penalty of no more than OUTLE TCHESfIXTU)# /S0
five hundred dollars($500). NEW R DENTIAL E SQFTA (ter
❑I,as owner of the property,or my employees with wages as their sole . . STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure isnot intended or offered for
O. sale(Sec.7044,Buabwsa arW Profemlow Cade:The Contractor's Lireme Law
$ does not apply to an owner of property who beliefs or improves thereon,and OCC.GROUP RES UNITS
does such work himself or through his own employee%provided that such
Improvements are not Intended oroffered for sale.If,however,the building or TOTAL:
Improvement issold w hM oneyearofcompleioytheowner-bu0derwiR have -
teE�rrdenofproving that hedid not build orImprove for Purpose ofsale.). ',QTl'. PLUMBING PERMIT FEEFLOODIOIE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec,7044,Business and Professioru Code:
The Contractor's License law does fid apply to an owner of property who �•�DRAIN&VENT-WATER(EA)Wilde or Improves thereon,and who contracts for such pipjects with a ..
<gtBfador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND.
SANITARY Y N
Owner .- s Date _ RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TA% Y_ N_
❑I hereby afftrm that I have a certificate of consent to self-Insure,or a - RECEIPT M
certlflrateofWorkers'Comperuation Ingemce oracedlfied cepythereof(Sec. , GAS EA.SYSTEM-1 llVC.40ITILETS PARK FEE Y T'
3800,Tab C3
Policymmy GAS EA.SYSTEM-OVER 4(EA) RECEIPC p
Com any .BUILDING DIV]SION FE ES
OCertuied copy ls hereby furnished. GREASE/INDUBT&L WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection division. ..
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER SANI'TAAY-STORM EA 200Fr. Date Re I t#
(Thlssedion need not be completed lithe permit is forom hundred dollars
($1lD)rtifytWATFRHEATERW/VENT/ELECTR ENERGYFEE Y N
I certify .)
that In the performance o/the work forwhlch this permit is Wued,
I shall not employ-any person In any manner so as to becerre subject to the
Workenn'CompensaHanlaws of California.Date WATRsYST%m/TREAnh)GPAID
z Z Applicant - - NEW RESIDENTIAL PLMB. SQ.Ff. "Date Recei t#
Z O NOTICE TO APPLICANT:If,ager nuking this Certificate of Exemption,you
should become subfoct to the Workers Comperuatlon provisioru ofthe Labor - TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING •E �
W > deemed revoked.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE [
I hereby affirm chat there is a construction lending agency for the C.) perform- ELECTRIC FEE
Z - ance of the work for which this permit is issued(Sec.3097,Civ. TOTAL:
U O lanaera Name PLUMBING FEE
LL F Lenderanddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l¢difythatlhavereadthisapphmtionandsUtethattheabovelnformation
4 iscorred.I agree to complywith al city and county ordirances and nate laws' PERMTTISSUANCE FEES PAID:
>. W relating to building construction,and herebyauthorize representatives of this
I— Z city to enter upon the above�rmrtloned property for Wpection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmieas the City of Cupertino Date Receipt#
V ago tIlablutiea,judgmenb,asssandexpenwswhlrhmaylnanywY.ame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag w Bald City 1 n,a ueace of the granting of this permit.
��(��"� AIR HANDLING UMT(OVER 10,000CFM) CONSTRUCTION TAX
Sigire of Appunnt/—Clontrador to allAUST HOOD(W/DUCT)_ CONSTRUCTION TAX PAID:
IronHAZARDOUSMATERIALS DISC SU
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R00e1 t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code ton 25532(a)7 HFA TING UNIT(OVER 100,000 BTU) TOTAL: S ]v
❑ Yes NVo .
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management E td . BOILER-COMP OHP OR 100,000 BTU)
4Yes a
havereadthehazar oratedalsrequlrementeunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Cade,Sections 25505,25S33 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. ,
res omanibilityto n
Xl3otify,the occupant of the requonmentswhlch mudbe met
loissu pq gI(icaMofOavpancy.
OG
°O f rr<eautho i TOTAL:
d agent Date ISSUED BY:
OFFICE COPY ` •of o