20847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Bulkileg Address: 2 0 8 4 7
0& orn
wn<ra ams: one: BMII"IALDAIE
iv,dk OF IkINiF-rI CITY OF CUPERTINO-BUILDING DIVISION r��o
Contractors Name: Lac.No: APPLICATION I PERMIT
-LI Cq - ISJ!;00 BUILDING-ELECTRSCALPLUMBING-MECHANICAL CATEGORY CONTRcr
Architect/En na. Lie No: 1St(7"
GSSG QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ��X(�
LICENSED CONTRACTOR'S DECLARATION Y'N
I hereby aff'vm that lam BM ceneunder provisions of Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DFSCKE'TION
ingwith Season 7000)of Divlslon3ofthe Buslnemand PmfessionsCode,and my
license Is In full fora and effect. PANELS T ,mill
LicenseCksiLLicM gLaTz-4t L `V " 1
Dao Contractor ,- a L)wrE (9wST. —UP TO 200 ANTS
ARCHITECTS DECLARATION 201.1000A.MPS
m0 Z I understand my plans shall be used as Public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FC.
O
rrd0 Llanxd Professiovl SIGNS ELECTRICAL o.0
6 OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MISC
Iherebyaffireathat lamexempt fronethe Contractor'sLicense lawfmthe
oo following reason.(Section 78115,Business and Professions Code:An tl or
CZI"'� county which requlrea a permit to construct,alter,improve,derolesh,orrepair TEMP.METER OR POLE INST.
�� anyiteacturepriortoitsbsaance,adsarequlrestheappll®ntforsuchpermitto POWER DEVICES
3 file a signed statement that he is licensed pursuant to the provisions of the
Ow Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
O son3ofthe Businemand ProfembwCode)arthathebexem therefromand VALUATION
the bands for the alleged exemption. Any violation of Section 7031.5 by any
a) <�
applicant for permit subjects 'scant too civil 1 ofeet morethan OUTLETSSWITCHESFIXFURFS r
F+j O f ve P rmi lea PP penalty J •0
c. five hundred won,lanhepe. NEW RESIDENTIAL ELECTA
Ina
^� I,asownerll the ✓ FL STORIES TYPE CONSTRUCTION
❑ property,or my employees with wages as their sok f—
cole(Sx a0on,Business workand ions ructure Code:Tknotintended oroffered for
O sale(Sec pf y to Business and f property
Code:The Contractors Gerson Law ^
who doss
apply toanowrrerofProperty who nem orlmprovnthercoryand
5� whodoessuch work himsel(orthrough Msownemployees,provided that such ` "o � �'0 OCC GROUP ftE5.UNITS
Improvereentsarenot intended oroffered forsale.Ifhowevegthebufldlegor :a.T AL: •CD
Improvement ksold wlthlnoneyearoRomplefon,the owner-bu0derwlllhave
th, *mlenofprovingthat h cixl not build mimprove for purpose of ode). QTY. L• BING PERTIT FEE ETpp ,NNE APN
L_j L as owner of the property,am exclusively contracting whh l3$ sed pp(MLI. PNCE; f
committees to construct the project(Sec 704y Businessand Peofssiov ode: !,� )� _
The Contractor's License law does not apply to an owner of pmperty ho RAIN k VENT-WATER(EA)
W IWI,or Improvn thereon, and who contracts for each p�o)ea.wlt(i is pLT92D
sem.. D
,I1!(ttor(s)Rcensed punuanttothe Contractor's LicenseLaw. IN . FEE SUMMARY
LJ I am exempt under Sec. B &P C for this MEN BACK W PROTECT.DEVICE
• Owner Date DRAINS FLOOR ROOF,AREA,4OND. SANITARY RECEIPT
WORKMAN COMPENSATION DECLARATION pp('TURF3.PER T1tAfP SCITOOL TAX Y_ N_
�I hereby affirm that I have a certificate of consent to aeB-Insure,or a RECEIPTNM
meffimts of Workers Compensation Insurance m a curtlfled copy thereof fSec. G�pA �.p -T,�C4DVD.EfS
3800,GbCd PARK FEE Y_ N_
I'o11ryR G3�"lob o3 - RECE9PTR
Co������mppppppanYJ�eL{TEU G EA. SEEM-0VER4(Fi1) BUILDING DIVIBION FEES
Cerlllldspyk hereby famished. GR E/INDUSIRL WASE INTERCEPTOR PLANCHECK FEE
Certified ropy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID �� 1.y_
:0
COMPENSATION INSURANCE SEWER-SAKETARY MRM E.A.2001T Date Rthmi Ip.LLA1!
Rhissectlon neednot M ncompleted If the permit b dollars ionone hundred dollars
(51 I crifless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
(certify employ
theperson
Iperformance any
work so as to b co permit is issued,
I shall not employ any perean In any manner w as to become subject to the WATER SYSIEM/TREATING
Workers CompensaHonlaws of California. Date PAID
C) Z Applicant_Z O NOTICETOAPPLICANT:If,after making thio Certiflcateof Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recei tN
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
WCC W Cade,you most forthwith complywith such provisions urlhls permit shall be
> deemed revoked. BUILDING FEtLp
t1 G CONSTRUCTION LENDING AGENCY SEISMIC FEE L 570
FEE
[hereby affirm that there Is a construction lending agency for the perform
Z ana of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ,DeJ
U O Lender's Ndme PLUMBING FEE
Iy h Lenders Addmsa QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W
01certifythatl have read this appllmtlon and smethat the above lnforrtution
M bcOmet I agree to comply with all city and county ordinances and sate laws PERMITISSUANCE FEES PAID:
>- Nrelating to building caemaion,and hereby authorize repmentativnof this
F Z city to enter upon the above-mentioned property for Inspectors purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeeiptif
against liabilities,judgments,"sand expenses which may Ina ywayaceme AIR HANDLING UNIT(T01Q000 CFM) SUBTOTAL:
againstsaIda in ron�qa c of the granting of this permit.
i Jit AIR HANDLING UNTT(OVER 10,"CFM) CONSTRUCTION TAX
Signature o(Applicant/Con actr
HAZARDOUS MATERIALS DISCLORE Idle
; EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IOQOW BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date ReCei tp
Healthand Safety Code Ion 25532(.)7 HEATING UNIT(OVER 100BTU)
,000 TOTAL: 8.00
F1 Yen . KNo
\ Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE REM) [f• Sp �c+,�+b-f�DATE
which emit hazardous air contaminantsas defined by the Bay Area Nr 47r�u i
Quality Management uo7 BOILER-COMP PtB'OK100,0(q BTU) se�'aB
en
have read the haza a materials requirements under Chapter&95 of BOELER-COMP(OVER 1 100,000 BTU) t V r the Callfomk I fezlth&Safety Code,Sections 25505,25533and 25534. I ✓ w.e5r
understandthatlflhe building does not currently have.tenant,that it 4 my NEW RESIDENTIAL MECH. SQ.I.7
rriorto has
tonracash fjo s aOccuperequiremenla which must be met a _
prior to�LssypCc of a Cepl is a of Oavpanry. 1�7`°IPR'se44a0RiwWw.
Owner or authonzN age ate
TOTAL: 6a sQ ISSUED BY:
OFFICE COPY