21413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Pro'ed Identification PERMITNO.
B°"°`° Address: _ 21413
wrero came: - one: A A
A10 CITY OF CUPERTINO-BUILDING DIVISION
.rose°araName: Lk.No: APPLICATION I PERMITAm 1'r
BUILDING-ELECTRICALI'LIIMBING-MECHAMCAL CATEGORY CONTROL It
Arch en/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PFRhIITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S pr DECLARATION
IhthSb ion7DCOffirro'latlamlk 3.fth.derprovisions andPffhonsC(..come APrLIANCFSRESIDENMl ]OB DFSCRIL ION
ingwith Sect1on7000)of Divislon3o(the Businessand Pro(esslonsCnde,and my
license is In tout and effect. PANELS
liense V ll Lk.N -2lL �/
Dale Centador /!/JCo/! UP TO 200AWS
ARCHITECTS DECLARATION 201-1000 AMPS
OpI understand my plaosshallbe used as pubRcrecads. OVER 1000 AMPS SQ.F7.FLOOR AREA S/SQ.FT.
Licensed Proleas oral SIGNS ELECTRICAL
G<^� OWNER-BUILDER DECLARATION
IhorcbyaSPECLLLCTRCUIT/MISC
fRmn that l am exempt from the Contractor's License Law lee the
7.9 following reason.(Section 7031.5,Business and Professlons Code:Any city or
county which requires a permit toemsteact,alter,Improve,demiolbh,or repair TT&M s RPOLE T.
anystmctum prlorto its bauance,aBo requlreatheappeantfor such permit to
Qfile a signed statement that he is licensed pursuant to the provlsium of the D
G Contractor's License Law(Chapter 9(mmme°cing with Sectkm 703T of Divi- WLTR
sion3oftheBuslnevand PmfesgmvCde)orthat heisexempitherefromand VALUATION
the basis for the alleged exemption. AnyviolationofSection7MISbyany applicant fora ponodsubjectstheapplleanitoadvil penailyufnatmorethnn r1/five hundred dollars(¢500). `� ❑I,as owner of the property,or my employees with wagesastheir sola RIES TYPE CONSTRUCTION7. compnaatlon,wit do the work and theillmeture is not intended or offered fesV D sale(Sec.7064,Business and Prolesslons Code:The ContractorsLicenssLw
(;' 2 docs not apply to an owner of property who builds or improves thereon,andOCC.GROU RS.UNITS
who docasuchwork himself orthwgh his own employees,provided that wch
Improvements are not Intended oroffcred forsale.IL however thebullding or TOTAL:
Improvement bsoidwithincreyeamfeampletion,the owner-bullderwlll have
t rden of proving that he did me build or Improve for purpose of sale.). Q PL BING PER FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively.....acting wit's Il.need IT CE
contractors to ronstruct the project(Sec 7064,Business and Prv(essimu Code: -
TTc Contractor's License law does not apply to an owner of property who A1.TFR DRAW&VFM
builds or Improves thereon,and who.ntnm for such pwisds with a
�!B(+dmr(s)licensed punuent to the Contractors License Law.' ggIX FLOW rROTFCT. E FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this reason
Owner Date DRAINS FLOOR F}s COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECFL'Tp
01 hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES-PERTRAP SCHOOL TAX Y N
ceniflateofWork m'Compe®atlonlreumn.oracenlfWd pyther.f(Sec. RFLEIPTN
3800,Labc) y 2 rT GAS EA.SYSIFM .d OU"ILE75 PARKFEE Y N
I'oliay tl J GAS FA.SYSTEM- V d(EA) RECEIPT M
Cam any BUILDING DIVISION FEES
Wined p4, herebyumecity GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Cenl(ied.py V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
(Thlssectlon need Am becempletedifthepermit isforone hundred dollars SEWER-SANITARY-STORM EA.200FT, Date Recei t#
(a100)orfesh) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cent that us employ
any person
in an thework so as tobeco become subject
N—
I shall not employ any person In any manner at v m become.bject to the
Workerd Compensation Lawe o(Callfornla. Date WATER SYST'PM/TRGTING PAID
O Z Applicant
Z in NOTICE TOAPPLI et to
aftermaking this cation ateof Exemption,you NhW RESIDENTIAL PLMB.__SQ,FT. Date Recef t#
F N Code be.mesurthwit the Workers'Compereatbns orchis permit
s Labor TOTAL:
Code,you most forthwith comply with such provisions orthta pemdt shall be
W > deemed revoked. BUILDING
FEE
S 0 CONSTRUCTION LENDING AGENCY FEE
I herebyafOrenNat there is a mrotruction lending agency for the perform
0 ance olthework forwhichthb permit 6 issiod(Sec,3097,Civ.C.) TOTAL: FEE
(,) lenders Name NG FEE
14, teraera Aaaress QTY. ,MECHANICAL PERMIT FEE NICAL FEE
O W I cenlfythat l have readthbappliatlonand state thattheabove,Information
1 Is rorred.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE ID:relating to building.nstruction,and hereby authorize representatives ofthlscity to enter upon the above-mentlonM property for Inspection purposes. ALTERORADDTOMECH.
(We)agree tosave,Idemnifyan d keep harmlesstheCityofCupertino Receipt#
against llabllltlesj+dg nts,sLa.ed expenses which may lnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL;
against said Cy�44 ron rare of the granting of this permit.
/ n AIR HANDLING UNTT(OVER IQOOOCFM) CONSTRUCTIONTAX
Sigrutu p Bant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulure building occupant store or handle hazardous HEATING UNIT(TO l00,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I❑Yesd Safcty Codre SSedloon 25532(.)7 HEATING UNIT(OVER 100Elm
TOTAL;
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DALE
which emit hazardous ale. mi
ntanants as defined by the Bay Arca Air p�y
Quality Management Distdct7 BOILER-COMP pFIP DR l00,fXU BTU)
qYea KLNo
have read the h ous materials requlrementa u refer Cha pier 6.95 of BOILER-COMP(OVERID0,000 BTU)
the California Health&SafetyCodCSsd1om2550S,25533 and 25536.1 NOVO.r„a /E
understand that lithe building does not currently have a tenant,that it ts my NEW RESIDENTIAL MECH. �,FT. 1'I IJV 1
rriorto us y auyt onvpartofihe requirements which most be met
prim.to us
ofd fiats of Occvpanry.
Own �i / Fri of
auth zed agent Date
TOTAL: ISSUED BY:
OFFICE COPY