20679 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY C
Building Protect Identification PERMIT NO,
Building Address:
as . 20679
wnero a(� one: A
TE
CITY OF CUPERTTN0.BUILDING DIVISIONO
Conraao sName: LIc.No: APPLICATION / PERMIT
eI ✓Vr BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL a
Archited/Engineer. Lie.No:
11 T •QTY ELECTRICPERMIT FEE BUILDING PERMIT-INFO
Address: Ll b✓ I ITRMITISSUANCE In 11 ❑
LICENSED CONTRACTOR'S DIiCLARATION
I hereby affirm that l am licensed under provisions ofChapter9(comment. APPLIANCESRESIDENTIAL JOB DPSCRII'TION
ingwBh Sedton7000)ol Division3 o(the Buslmssand Pmfesdons Codaand my
lienee Is In full forceaIld dfect PANELSse
Licenldn L
C.
#
Date Contractor
ARCHITECI•S h
ECLARATION 201-1fA0 AM
X I understand my plans shall be used as public records OVER1 SQ.FT.FLOOR AR S/SQ.Fr.
CO
u Licensed Professional SIGNS EL L
�< OWNER-BUILDER DECLARATION SPECIALCIt T/
ZLo., '.6 1herebyaffirm that Ism exempt from the Contractor's License Law for the
OZ following reason.(Section 7R)IS,Business and Professions Code:Any dy orP.M O
PE county which requires a permit to construct,alter,improve,demolish,or repair
�L any structure prior to Its Issuance,also require the applicant for such permit to WER
q a file a signed statement that he us licensed pursuant to the provisions of the
3w Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvl- gN, TR[
G LELGC
�Og Sion 3 ofthe Business and Professions Code)orthat he is exempt therefrom and VALUATION
the Fiats for the allegedexemption. Any vlolatlon of Saekm 7QHS by any ��-)
O<5
applicant for a permit subjects theapplcant I.advll penalty of net mare than SWI�HESF7%7l1RFS 0 (N/
live hundred dollars B ISM.
_ ❑I,as owner of tM property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STO FS TYPE CONSTRUCTION
compensation,will do the work,and the strucNre is not intended or offered for
0, sale(Sec.70K Business and Professions Code:The Centimeters License Law
�$ does not apply to an owner of property who build&or improves t hereon and OCC.GROIRa RFS.UNITS
doessuch work himself orthrough Msown employees,provided that such
improvements arc not Intended oroffered forsals.If,however,thebuildingor TOTAL
improvementissold withlnoneyearofcompletion,the owner-bullderwill have
the burden of proving that he did not bund or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FIAODTONE APN
0 4 as owner of the property,am exclusively contacting with licensed - PERMIT ISSUANCE
conte cton to mmtroct the project(Sec.7014,Business and Profenions Code:
The Contredorn s License Law donot apply to an owner of property who
buALTER:DRAIN kVENT-WATER(EA)
Wild.or Improv.thereon, and who contracts for such ptojeds with a
colgpad.,(.)If...d Pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_I I am exempt under Sec B A P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N_ ,
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑1 hereby affirm that I have a certificate of convent to self-Insure,or a FIXTURES PER TRAP SCI'IOOL FAX Y_ N
cemflcate o(Worken'Compensation Insurance orecertifled copy thereof(See RECEIPT#
GAS EA.SYSTEM-i INC.4 OIIILETS PARK ITE Y N
Poltrylis[ab CJ
PaM DING DIVISION
f M
Com an GAS EA.SYSTEM-0VER4(EA)
Y BUILDING DI V ISION FEES
Certified copy Is herebyfamished.the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certi(Ied copy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE Date RCCCI IN
Rhis seetion need fid M completed lithe SURApermit Worms hundred dollars SEWER-SAI'MARY-SPORM FA 200Fl.
(8100>arlen.)
Icertifythat In the performance of the work for which this permit I,Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Yued, N_
I shall no'
creel my pereon In any manner eo pm(r�epyled to the WATER SYSTEM/TREATING
Workers'Comp tion laws Ilfornla.Datea��jp-I"1d PAID '
C• Z Applicant
B NEWRESIDENTIALPLMB. SQrr. Date ReE !#
Z O NOHCETO ICA e R making
omthus
sation Certificate of Fos of
,you
1" should become subjects a erken'Compewatlon provisions of the Labor TOTAL:
Ix N Code,you most forthwith comply with such provlslons orthis permit shall be
j devoted Invoked. BUILDING FEE
d SMIC
C CONSTRUCTION LENDING AGENCY SEI
1 hereby affirm m that there Is a construction lending agency for the perform. EE
SM IC FEE
FEE
= ae..f the wmkfor which this permit b leered BSec.3097,Civ. TOTAL: EL
O O Lenders N. PLUMBING FEE
LL 1— Lendce.Address QTY. MECHANICAL PERMIT FEE.
MECHANICAL FEE
O W I certlfyshatl have readthis application and aasethattheabove information
A coned,I agree to comply with all city and neuntyordleanres and pate laws PERMIT ISSUANCE FEES PAID:
} C relating to building ronstrudion,and hereby authorise representatives of this
Zcity to enter upon the abuvcmentiouN property for Impecsion purposes. ALTERORADDTOMECH.
(We)agree to cave,Indemnify ao d keep harmless the City of Cupertino Date Recei t#
V against liabilities,j.dgments,costs and expenses which may In any w.yaccme AIR HANDLING UNIT HO ins10,000 CFM) SUBTOTAL:
agat said City in consequence of the granting a(his permit.
AIR HANDLING UNIT(OVER 10,"CRD CONSTRUCTION TAX
Signature of Applicant/Contactor Date EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant orfuture building occupant emreor handle havardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Hes lth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTLB TOTAL:
❑ Yes M No
Will the a pplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSIO) ISSUAIR$&DA4�
which emit hamnious air cont.enrants as defined by the Bay Area Air ��f/''�Yjii�IJJ
,Quality Management District? BOILER-COMP,QHP OR 100,OM BTU)
4.. gNo
-Th.. ad the Fara ouy Cede,abrequiremenb3533 and 2S534.
of BOILER-COMP(OVEt 100,000 BTU)
,the Callfomla Health k Safety Code,SMIcns 75505,25533 and 75534.1
'undo fid that if this building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. of,
sh p
resp ns Ilitytonotify the occupant ofthe requimnlentswhich moatbemet City, �IUpBrtIpB
pri r Issuance rtlficateof Oc parry. e
Owner rauth a nt 111a
TOTAL: ISSUED BY: `t"
'
OFFICE COPY