23737 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY .
Building Project Identification PFIMITNO. -
BulldingAddress: /Aq I�
/ 670ro I-Muter �1 1L Gu{ u(
-
A
ko tlexT V-++IEY 737- 994y CITY OF CUPERTINO-BUILDING DIVISION
C cnna ora Na!me--:. Lm.No: APPLICATION / PERMIT 214021
yoI BUILDING-ELECTMCALMUMBING-MECHANICAL CATEGORY=Lp
Architect/Ggineer. - Llc,No:
,QTr ''ELECTRLC PE6INIT ,: F�& � '-iBUILDING PERMIT,INFO ' •"
Address: PERMITISSUANCE ❑ ❑. , • .❑.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I son licensed under provisions of Chapter 9(commen APPLIANCESRESIDENMIL TOB DEscam
tngwith Sedion7000)of Divielon3ofthe Businessand ProfesstonsCodgand my - -
license Is In fuB force and dfect. PANELS R� � tlpf
License Claes E le Lia a CsYO ' ���a..� G1
Contractor Atp U 10 200 AMPS "ARCHIT'ECT'S DECLARATION 201-IMOAMN '
{qq{�000 ]understand my playa shall be used upublicrecoMw OVER 1000 AMPS SQ.Fr.FLOOR AREA ,$/SQ.FT.
Fe (/ Licensed Profeseiarui SIGNS ELECTRICAL . . -
<<� OWNER-BUILDER DECLARATION SPECIALCB2C /M ,^ I�
z � IherebI.yaf8renthat Iexempt from the Contractor's License Law for the
following reason.(Section 70315,Business and Profession,Code:Any city or
Fl countywhich requlreatrsectmre
sa peronowcon ,alter,improve,deolish,orpair 7EMP.ME ERO OL ]NST.
q ..l anystructure priortoltsismance,alio requtmathe applicantfor such permAto '.> �, _ . r✓
6 a file a signed statement that he Is licensed pursuant to the provisions of the EWER DEVICES
w Contractor's Llcenae Law(Chapter 9(commencing with Section 7000)of Divi-
sion SWIMMING]Y)O ELECT '
�0 3 ofthe Business and ProfessimrsCode)or that he R therefrom and therefroand VALUATION .-
�' the bash,for the alleged exemption. Any violation of Section 7011.5 by any
4 applicant fon permit subjects the applicant to a civil penalty of not more than OUTLETSSWITC "
` five hundred dollars(5500).
F]I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELEC7R
SQ'IT STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offered for
g M sale(Be.7014,Business and Precfemiora Cade:The Co dmetc's License Law
�•� does not apply to an owner of property who builds or improves thereon,and OCC GROUP
RFS,UNITS
P. who doessuchwork himselforthrough hisownemployees,provided thatsuch
improvements are not Intended oroffered forsale.lf,however,theWilding or TOTAL:
Improvements„old withinoneyearofcompletioMthe owner-bullderwiil hav
tt v den ofprovingthat he did notbuild orlmprove forpurpos,ofsale) QT�•` '(�" . 'Pt ,UMP1tRMIT :F.EE FLooD weds pPN '
u I,as owner of the property,am exclusively contracting with license
contractors to construct the project(Sec.70K Business and ProfPERMIT ISSUANCEeadons Code:
The C6.1oxa r'a License Law does not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts -
for such IsTirc ,with a •; .
cg6tI dor(s)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
PEE SUMMARYLJ I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date WORKMAN COMPENSATION DECLARATION RECEIPT p
MIX
QI hereby affirm that I have o lmum to of consent to spythsure,(S a N. PER s SCIdOOL TAX Y_ N
certificate of Worker Compensation lruuranceora mrti(kd copythereof(Sec. - RECEIPT
Polis Leis C.) GAS EA.SYSIEM-]INg40UTLETS PARK FIS Y N_
Policy p — RECEIPT p '
Cam any GAS EA,SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Certified copy is herebycity
turnlahGREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
- �Certifled copy b filed with the ty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' G PAID
COMPENSATION INSURANCE
(Thlssectionneed net becompleted ifthepermit isforons hundred dollars TRAP TARY-STORM EA.200FT, Date Recei tH
-
($100)or lea,.) VENT/EL[CTR ENERGY FEE Y N
Icertify that in the performance of the work for which this permit is issued, - —
I shall not employ any person In any manner so as to become subject to the ATTR BY / TlNC
Worker Compensation Laws of California. Date PAID
Z Z Applicant ' - "
Z O NOTICE TO AI'PLICANrT f,after making this Certlfl roof Exemption,you NEW RRDDENTIAL PLMB. SQ.F. Date _ ReC21 t#
should be..sobjed to the Workers'Compensation provisions of the Labor TOTAL:
W-
Code,you=at forthwith comply withsuch provisions or this permit shall be BU DING •E
W > deerned revoked.
a CONSTRUCTION LENDING AGENCY - SEISMIC FEE - - .
I hembyaf8rm that there is a construction lending agency for the perform T ELECTRIC FEE
O 'ance of the work for which this permit is Issued&r.3097,Civ.C.)
V Lenders Name PLUMBING FEE �"'�
0 F LendcraAddress QTY, ,:,,.MECHANICAL•PEENT :FEE:'.,': MECHANICAL FEE
O W •Iechifythatl lave read thisapplicationand statethattheabove lnfarmallon
1 ucorred.I agree to comply with all cityand county ordinances and state laws PERMITISSUANCE FEES PAID: y,
} N relatingtobullding comtruction,and herebyauthorisee representativesofthis ,
I— Z chyto enterupon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify and keep harmless the City of Cupertino Date ReceiptN
against liabilities,judgments,costs and expenses which may In anyway accrue AIR HANDLING UNIT(7O 10,000 CPM) SUBTOTAL:
ga inat d City in consequence of the an tingofthlspermit.
_—y1. -2.7_7,2 AIRHANDLINGUNIT(OVER I0,YYCFM) CONSTRUCTION TAX
Sig atureaf pplicantt//JContra or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
.HAZARDOUSMATER SDISCLOSURE
` Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BN) Date Recei
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Section 25532(x)7 r HEATING UNIT(OVER I00,04M BTU TO
Yea No -
Will theappilcantNturebuilding okupantuseequipmentmdevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit havardous air contaminant,as defined by the Bay Area Air /ted/N
Quality Management Dlstrld7 BOILER-COMP QHP OR 100,000 BTU
Yea [ No
AFF_ V
4havereadthehazar?usmaterialsrequirementsunderChaper6.95o( BOILER-COMP(OVER100,OW BN) ,nAYz
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQ,FF, P, Qa•r�
priorirespoIssuay to nce
notify the icteof of pancy.he lremxnlawhichmustbemet T yllYUr lg
prior to Issuance ofa Certificate ofOmpanry. L'ur
I �
Owner or authorised agent Date ISSUED BY:_ �
7DTA7.:
OFFICE COPY