20599 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - i Plumffr NO. -
BulldingAddress: • t ,
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�d CITY OF CUPERTTN0.DUILDING DIVISION �r Z-�^G] D
APPLICATION / PERMIT 4
ONd '� QW I��C/l YG V BNLDINC-ELECTRICALPLUMBING-MELHAMCAL, CATEGORY CONTROLp D6 Y
Architect/Ggf Lie Na
Q ♦ 4r �EJ r M
QTY ELECTRIC PERMIT. r�FEE > BUILDING PERMIT INFO
Addreas:/4/J Y Ldt'//Q `Q✓E' lea ��{K PER UTI55UANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9 mmmene APPLIANCES RESIDENTIAL ]OB DESCRIaRTON
ingwlth Sedkm7000)of Divlslon3 ofthe Buolnessand ProfesslonsCode,and my
license Is in(uC u ra+and effM. p I I'ANEI3 u Q 1• I �<��/,
Lienee leu Llc.p [ 1 I 50
Date ContndorUP TQ200AM5
ARCHITEe uwd .CLARATION OVER10AMf5
Ob
7 I understand my phu eMB M used as public remNa OVER 1000 AMPS SQ.Fr.FLOOR AREA. S/SQ.R.
p•�
SICNSELDCTRICAL - Nei,/• dv1C .37./• [ 2
IL Licensed ProfessionalPa q
6 OWNER-BUILDER DECLARATION
i`n Ei SPECIAL CIRCUIT/M �_l
f, Iherebya(Brrnthat l am exempt from the Contractor's License Law for theVlesf)'9 Z��'
�p fo0owing reison.(Section 7031 S,Buelnessand Profeasla..Code:Any city or -
Z F TEMP.MEIPR OR POLE I T.
�� mustmerohregWresapeuNttomrorequireathe lter,l apmvgdemolbh,ormit to n/ p
any.tmtturc i.tano itsthat
heIssuance,abored!pursuant to
foravah permit a)1PERNUT
)OWER DEVICES far H�l+/��� I C
floe a signed statement that he V r9(. pursuant it the proWlOns f the
Ou, Contractor's License Law(CMpter9(mmrrendng with Sedlon 7000)of Divi. V s VALUATION
3 sv,'IhLNINc 170E F�-e• c,
elon3ofthe Buelneu and lsrofessbns Code)orthat he Vexempt therclromand w r f,av p dd
the basis for the alleged exemption. Any violation of Section 7031S by anyUT(,ETS,SWITEHPSFI%IVItFS' / •�
applicant fora permit aubjecta theapplicant to a civil penalty of nor more than 3
five hundred dollars ISM, yw�..rr+a 0'
V
�n
1,as owner of1Mproperty,orhe employerswith wage a.their dfo
7iW ftESIDIrNTIAL EL 50. STORI: TYPE CONSTRUCTION
k Ci
compensation,will dess andothe rl4ansame, udurebnet
Contactor°kens Lit. k, O -
$�❑ ole(Sec.7614 Business and Profmlons Code:The CoNradole License taw
P'j3$ does not apply to an owner of property who Wilde or lmprwes thereon,and OCCGROIIP RFS.UNITS
C whodoessuchworkhlmulforthrwghhleownemplayeee,pr°vtded thatwch
Improvementsamnot Intended...fferedforsale.lf,however,thebuildingor T AL:LfG�aro
Impmve.nt[swidwithinoneyearo(completion,theowner-bu0der Mithave t
tFLe��rden of proving that Mdid not Wlld orlmprove for purpose oleale.). kUMBING ERIT FEE FLCODZONE , APN
4 aeowner o!the property,am exclusively contracting with licensed •ISSUANCE
1•"1
Contractors to mrulruct the project(Sec.7064,Business and Professions Code: V1+
The Contradorb License Law dm net apply to an owner I property who -
W Rds or Imprwn thereon,and who mntnds for such penjeds A DRAIN&VENT-WATER(E/s)with a
o�Btactor(s)licensed pursuant to the Comradoem License Law. - FEE SUMMARY
LJ I am exempt under Sec 0&P C for this reason CK FLOW PROTECT.DEVICE OUTSIDE 1111's
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner Data _ RECEIPT
WORKMAN COMPENSATION DECLARATION pTXTR7Rpg.PER TRAP �aa�.� SCHOOL TAX Y N
®1 hereby affirm that I have..carHflcate of anent m sell-Inwre,ora 8 W RECEIPT X
mdiflobc.Workers'Compensatonlnsunncemacertllhd copy there°((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
3BW,lab C.) ♦ p
Policy p_�J I sf t i �O GAS F.A.SYSTEM 6(EA) ' RECEB'T It
Comany a- Q u BUILDING DIVISION FEES
Certified copy b herebydwith he city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE (�G
Certified copy is filed with the city lrupedlan division. CC �
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP noPAID
COMPENSATION INSURANCE SANffARY
(Thl..edkm.rxd t becompleted lfthep°emit bSEWEIL
(orone hundmddollere STORM EA.200FT. Date Recti t#
($1I remlyth WATER HEATER W/VFNT/ELFCTR ENERGYFEE Y N -
I ll not emploIn y
he any pelma in an the m workmanner
so as towhibecis ome
la booed, t��l•
I shall not employ any penws In any manner ao u to become aubktt to 1M WATER SYSTEM/TREATING
Worlica Compensation laws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PLMR. - SOFT. Date Recei t#
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption you
should become sub°to the Workeri Compcnsetlon provisions o(the Labor TOTAL:
tl) Code,yau mu at forthwith comply with wch provhhms.1thi.permltahallbe 33�a�
> deemed revoked. '
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE D�
CL Ihercbya(Orm that there b a construction leading agency for the perform, 3 ELECTRIC FEE
Z ancc ofthe workfor which this permit is Issued(Sec.30W,Civ.C.) TOTAL: 22co �6
U O Lender.Name PLUMBING FEE"
IL F Lendee.Addreas QTY. I MECHANICALPERMIT FEE MECHANICAL FEE
OW I.Aifythatl Mvereadihhapphcationanddatethattnc..,ln(ormatlon -
C bcorrect.I agree to comply with all city and county anllnances anti state laws PERMITISSUANCE� - IZ FEES PAID:
>_ relatingtobuildhgmmuudlon,and herebyauthodumpreentativesofthis -
'� Z
City to enterupont bove-mentioned property for inspection purposes. ALTERORADDTOMECH. 2s f�
(W a agree to ,Indemnify an d keep harmless the City of Cupertino Date Recei t#
'V .,agalut habilid"468manA.,oust dex nese whi hmaymanywayamue AIR HANDLING UNIT(TO 10,000 CFM) - SU13TOTAL:
agal cal mnoequena arm ming of this pertnlL AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
SiwWre Applicant/Contractor Data IXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUSMAT it ,SDISCLOSURE
Wil .applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date 'RBCeI t#
note al asdeflned bytMCupertIm MuNcipal Cole,Chapter9.17,and the -
Health and Safety Code, on 25537(2)7 HEATING UNIP(OVER 100,000 RTU) TOTAL: a,
❑Y.
Will theappll or tore building occupant use equipment or devices ,I VENTILATION FAN(SINGLE RESID) 2V� ISSUANCE DATE
which emit hazardous at mntaMnsnts as defined bythe Bay Area Air
` fj alBy Management Dls r�t7 BOILER-COMPpFB'OR 100,000 BTU)
Yea
have read the Fdz Irs'etymaterialsCod .requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Beal &Safety Code,Sections 25505,25533 and 25536.1
understand that bulldingdou not currently have a tenant,that it Is my NF.W RESIDENTIAL MECH. SQ.F7 v 1 t il3sv
ruporuibllityt Ify the occupant of th qubemenis which rrwslMmet
prior to Lasy a e aCanlfIc.1 f0c nry, _��' cit,of
OJ�erero uthodud agent �� y Date _ M ISSUED BY 41,7 -
II TOTAL: CO
OFFICE COPY