20620 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.Ildlet,Neiea Idendflcation PERMITN/O. gI''�a ^/
BuiMing Add
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TYWnen amn; one; . -
)LTJ 2.toy-J Q CITY OFCUPERTINIaBUILDINGDIVISION Com'--2 2'— q0
Cmanmr'e ' R17Uc.No; APPLICATION i PERMIT
5� BUR-DINGELECTRICA4I'LIIMBING.MFCHAMCAL CATEGORY- CONTROL
Architect/Enginesr. Llc No:
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERhRTI55UANCE - _❑ ❑ ❑
PLUMB mi�li
LICENSED CONTRACTOR'S DECLARATION ChON
I hereby i(lrmllut Divisi am 3aftheBusi vend Pmfessim r9(mmmenc APl'LIANCESRESIDENFIAL ]OB DESCRIPTION
Ing meh5M1on7000)o(gvLvion3a(the Bucimvand ProfesdansCode,and m -
Ilanse Is IZn/n�_feJc'(��d effect. a� /r� PANELS
License CIa6v—A"-/ Lie Y
Date Contractor -
ARCHITECTS DECLARATION' 201'1000 AMPS' /-
reOZpC lundentand my plans shall be used sspuhhdrecorda OVER 1000 AM SQ.FT.FLOOR AREA $/SQ.FT. '
U Licensed Professional -WNER-BUILDER DECLARATION SIGNS ELECTRI
6 OSPECIALCIt T/
z � IherebyafBrtnlhat l amexempt from the Contractors License Law for the
.rJ4 ^ following resson.(Seefon 7031.5,Business and Pmfmione Code:Any ct y or
C^Jv] countywhlchrequimsaper ttommtmctaltepimpmve,de=lleh,orrepair TEMP.MET EIN
mystmcture pdortolts Issuance,also requlreatheapplIant fonuch permit to
�K Me a signed statement that he Is licensed pursuant to the provisions of the DEVI
�Gµl-n Contractor's License Law fClupter9(memencing with Section 7000)a(gvl- NG LFL C VALUATION
0< elon3o(lhe Business and Professloru Code)arthat he V<zempr therefror
Q J� the balls(or the alleged exemption. Any violation of Section 7m1S by any TNEWDErMA7LL
TCH FS / �•/q
aPph.nt fora perinit subjects theappllcani to s inll penalty of.&momthan
five hundred dollars(550(f. LEC
❑I,as owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
vie(Sec.7004 Bualmss and Professions Code:The Contractor's Lim.Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS,UNITS
EE whodoessuch workMmveRmthwgh hisownemployea,provided that such
Improvements are not intended oro(fered fmvk.If,lu wever,thebuilding or TOTAL: .'
Improvement lssoldwithinoneyearo(campletlon,th<owner-bu0derwlll have
tryll.tIu rdm of proving that he did not build or Improve fm purpose of sale.). QTY, PLUMBING P MIT FEE
FLOOD ZONE APN
LJ S as owner t the property,em exclusively Business
and Ing wkh.Codd PERMIT ISSUANCE
mouTh.CmarstommWnseet Law doe(Sec.appy to
sane P al
Cade:
The Caor Improves
es the Law does oat apply ro an owner I property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve Nsa, and who mnemes, 1w such wMojem with a FEE SUMMARY
,➢t.[+ct'm exempt under
Spursuant ro the Contnctm's License P Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B &P C for this reason
•
OUTSIDE FEES
Owner Dale
DRAINS F=P,ROOF,AREA,COND. SANITARY Y_ N,RECEIPT Y
WORK MAN COMPENSATION DECLARATION FIXT.U�S PER TRAP SCHOOL TAX Y N
❑T hereby affirmorker that I have o Insurance
of consent to apytheure,(Sa RECEIPTY
MOD,abte o(Worken'Campeaatlon Insurance ora artlfled mpythereot(Sec. GAS EA.SYSITM-1 INCA OUTLETS PARK FEE Y 4 N
3800, 0 C.)
Pollq•Y RFxEBT M
Cra
GAS EA.SYSTEM.OVER 4 2U BUILDING DIVISION FEES
�mpany
I )CertNed copy is hereby furnished.city
e ity E/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ,
I'�dl
Certified copy b filed withh the cIrupec[lan division. GREAS
CERTIFICATEOFE%EMPFION FROM WORKERS' GREASE TRAP PAID /
COMPENSATION INSURANCE
(Thlssectlonneedna becompleted ifthe permit isforons hundreddollara SEWER-SANTTARY-SIDRMEA.200FT. Date • Recei tk
($10(fimles.) WATER HEATER W/VFTI.T./ELrc.TR ENERGY FEE Y' N
I anifythat In the performance ofthe work forwhich this permit to issued, ,
I shall not employ any person in any manner n as to bemme subject to the WATER SYSTEM/TREATING -
Workers'Compemation Lewso(Califomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FL Date Recei 'tht
Z O NOTICE TO APPLICANT.If,after melding this Certificate of Exemption,you ,
should become subject to the Wmimes'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such pomiaims or this permit shall be I BUILDING FEE
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby offimnthatlherebamruttu tion lending Issued(Sec.3agency7,Chr. .) perform ELECTRIC FEE
C) Z ance Lmderthe work(or which this permltlsksued(Sec.3097,Civ.CJ TOTAL;
V O Tenders Name -. . '� � PLUMBING FEE
H Lender.Addma QTY. - MECHANICAL PERMIT FEE
O W l.difythatlhav madthhappBatbnandstawthattheabovelnformation MECHANICAL FEE
IL iscorrert.I<gme to comply with all city and county ordinances and state laws PERMIT ISSUANCE - FEES PAID: S,
>. relating to building comtrumm,and hereby authmioe representatives of this c
N city to enter upon the above-mentioned property fee inspection purposes. ALTERORADDTOMECH.
? (We)agree to uve,indemnify an d keep harmless the City of Cupertino Date Receiptk
V' agaWtliabNtks,judgments,coat end ezpenanwhichmayinanywayaccrue AIR HANDLING UNIT(TO 10,ODD CFM) SUBTOTAL:
agalat old tyl/9,��conscquena he granting o(thk permit AIR HANDLING UNIT IO,000CFM) CONSTRUCTION TAX
"" G-2�-g CONSTRUCTION TAX PAID:
Signature 6l'APp antes /Comactoi Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant mfuture building occupant store or handle hazardous HEATING UNIT(M 100,000 BTU) - Date Recei tp
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ,
Health and Safety C mon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea
o RS
Ill the applkanl future building occupant use equipment or devices � VENTILATION FAN(SINGLE R[5Iq ISSU�{Q�TE
which emit hazardous air iontammanta as defined by,the Bay Area AB LG[pV,�(� ..
Q_.Jity Mawm
geenl District? BOILER-COMP OHP OR I W,IXD RTU)
L-I Yea
I have read the haza�omalerfals requirementsunderChapler6.95 of BOILER-COMP(OVER I00,OOD BIM (JUN 2 819MU
the have
Health&Safety Code,Sections 25505,25533 and 25530.1 -
understandthatif the building does not currently have a tenant,that it lsmy NEW RESIDENTIAL MECH. 'SQ.FT. as�p��
responsibility to notify the occupant of the requirement,which most be met PTI
prior to uame gf-Certi t fOaupancy. 6-2-9, ""•e: YSsj LslGWIaC'
Ownermsutfimi dage'nt Date - -
TOTAL: ISSUED BY: V e /CY.I• �V
' , rT
OFFICE COPY