21063APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bullate Pm'ert Identification
PEIt.MITNO.
HugoAddress:
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21063
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CITY OF CUPERTINO-BUILDING DIVISIONU
APPLICATION / PERMIT
BUILDINGELF MCA4ML BINGMECHANICAL
r
S.a9ba oNa LIc.N.
&& 8--3olOb
CATEGORY
CONTROL#
ArchibeettEngireer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INF
Address:
1. X ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm, that lam licensed under provblons of Chapter9 (commmc-
APPLIANCES RESIDENTIAL
J09,QESCRII'IION
PANELS
hrensetl anddletT.3o-ft7heBmis , and my
I
(cense Cl Liep
Contractor
201.1000AMPS
ARCH ITEOPI CLARATION
I understand my plans shall W used as public records
OVER I"AMPS
SQ. FT. FLOOR AREA
S/SQ. Ff.
SIGNS ELECTRICAL
Licersed Profealmal
SPECLILCIRCUIT/ML
OWNER -BUILDER DECLARATION
I herebyaffirrnthat I am exempt from the Contractor'. License Law for the
fogowingreason.(Section 70313, Businessand Professlons Code.Anyeltyor
county which reclaims pemdttoconslruct, alter, Improve, demolish, oreepair
TEMpM RPO \
anystructure prlortoits issuance, also require,the applicantfwsuch permit to
file a signed statement that he b Bmrsed pursuant to the provide. of the
IpWp3(DEVI
SWIM G PAGCTRI
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
aton3of the Business and Professions Code) orchil he b exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 7[01.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more the
0[TfLE FS
five hundred dollars (S500).
❑ I, as owner of the property, or my employee with wage as their sole
NEW R AL EI. TR FT.
SID fs
TYI'ECONSTRUCTION
comperuation,willdo the work and the structure Its not Intended or offered for
sale (Sec. 704y Business and Prvfessbw Code: The Contractors License Law
does not apply to an owner of property who Wilds or Improves thereon, and
whodoessuch workhmuelforthugh hisownemployees, provided thatsuch
m
OCG GROUP
RFS. UNITS
improvement, are not intended oraffered for sale. IL however, thebuliding or
TOTAL:
Improvement taxed within oneyearofcompletiory the owner-buRderwlll have
mnram of proving that ne am rat WBa or improve for parpa.e ar.ale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See. 700A Business and Professions Code:
Q PLUMBING PE MIT FHE
HOOD IDNE
APN
P RISSUANCE
The Contractor's License Law doe not apply to an owner of property who
Wilds or Improves thereon, ..it who contracts for such p,,. with a
�g6tjacto(ii)Brenda pursuant to the Contractor's License Law.
L,J 1 am exempt under Sec B A P C for this reasonOUTSIDE
TQLDRAIN &VENT -WATER (EA)
FEE SUMMARY
RACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
BBC=M
Owner Data
WORKMAN COMPENSATION DECLARATION
[ hereby affirm that I have a celtllkate of consnt to m[Wesure, or a
certificate ofWorkea' Compensation insurance or a certified copy thereof (Sec.
3800, Lab C.)
PER TBA]'
SZHOOLTAX Y_ N_
RECEIPT M
GAS -EA. SYSTEM -1 INCA OUTLETS
—
PARK FEE Y N
RECEIPT p
Policy p
any
CoS
EA. SYSTEM -OVER d (EA)
BUILDING DIVISION FEES
F3om
Certlfied copy b hereby famished.
Ej Certified copy is filed with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF D[EM PTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200FI'.
COMPENSATION INSURANCE
(Thbsedion need not be completed If the permit b furore hundred dollars
Date Remipt#
WATER HEATER W/VENT/ELFCTR
ENERGYFEE Y_ N—
($100)or less.)
I certify that In the perfomanm of the work for which this perms b bored,
WATER SYSTEM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of Calffomla. Date
PAID
NEWRF9DE1VHALPLViB. SQ.FT.
Applicant
Date Recti t#
NOUCE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
BUILDING '•E
00 �n
�[-/"'
Code, you must forthwith comply with such provision, orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
LW
TOTAL:
ELECTRIC FEE
I herebyafflrmthat there ba construction lending agency for the perform,
arm of the work far which this permit b bated (Sec. 3097, Cie. C.)
Lender'.Namc
Lender's Address
I certify that I have read this application and Gate that the above information
bcormd. l agree to comply with all city and county ordinances and state law,
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relatingtobulldle, constroctio, d herebyauthorom repreaertatives ofthb
city to enter upon the above loved property for Wpection purposes.
(We save, i I an d keep harmless the City of Cupertino
agar bllitle a and expenses whlchevylnanywayaccme
ago t m y apl seed granting of this Inmost.j
ALTERORADDTOMECH.
Date Recti t#
P
AIR HANDLING UNIT (TO l0,000CEM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CIM)
CONSTRUCTION TAX
IXHAl15'I HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
(gnatre of AppB r Date
HA2A R DOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date ReceI t#
Will the applicant or future building occupant store or handle haeardous
material a, defined by the Cupertino Municipal Codu, Chapter 9.1 7, and the
Health and Safety Cod on 25532(.)7
❑Ys o
Will the applicant future building occupant use equipment or devices
whicl harardou contaminants as defined by the Bay Area Air
Quality Mawgemc
Yo No
enbunder Chapter G95 of
4have read the ha. ou, ngod2l
HEATING UNIT (OVER 100,000 BTU,
' " • • TOTAL:
VENTILATION FAN (SINGLE REED)
x ISSUANCE DATE
Irflr�/rr,,,_�._
% L
BDrI FR -COMP 0HPOR I00,00i0 BTU)
BOILER -COMP
the Califomla Health Safely 505, 25533 and 75536. (
MM
NEW RESIDENTIAL MECH. SQ.FT
unders of thebuildingyhave a tenant, that lc b my
eo rements which must be me[G cat
,
ISSUED BY:
Owner or author gent/ D
TOTAL:
OFFICE COPY