20299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PELMITNO:
Bullding Address:sv6 20299
,
nenams: � ff one: APPL1CArU79U9RrM—Ar=A
b CITY OF CUPERTINO-BUILDING DIVISION r^�
Contractors Name: ik�`n: APPLICATION / PERMIT 5 v! qo
,: ' BUILDINGFLFCTRICAL-PLUMBING-MECF LAICAL CATFCARY CONTROL N
rchites/Engineer. Lk.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addm99
PEtM17755UANCE 1:1 ❑ ElLICF.NS ED CONTRACTOR'S DECLARATION
I hereby
)ofEmBcrosedheunder Busiessan MolGhapter ssions9de,and c AIsIsLIANCESRESIDE L JOB DFSCRE'[lON
licameh I.
70W)ofd diedn3ofthe Bugnevand Pro(esalonsCode,and my
Lima Is In fu8 force and k.# PANELS
Limns Ckss Lk.N a'.11
Dale GSer 201-1000 AMPS Vc`--�
ARCHIFEHITECPSDECLARATION
0Z Iundentand my plans shall be used apublicrecords OVERt AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
CO SICNSEL CAL
(� Licensed Professional
OWNER-BUILDER DECLARATION SPECIALC T/M
l., 1hembyaflam that am exempt fromthe Contractor's License Law for the
Ot- following reason.(Section 7031.5,Business and Professions Code:Any city orST.
��^p� county which requims a permit to mostruct,alter,improve,demolish,compair
P. PO
.c anyswnure prlorto lm issaance,ako requlmlheappBcant(or such pertNt to D ES
r F() file a signed statement that he U Bcane i pursuant to the provision,of the
Ou, Contractors License Law(Cleapter 9(commencing with Section 7000)of Divi- L ECTRI VALUATION
g.nloftheBugnessand Prfenlor,CWe)orthathebexempt therefromand
6 5 the busts for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SWI FI
applicant fora permit subjects the applicant to a dvil penalty of nmore than v
five hundred dollars MW. NE ENHAL EL }T.
❑I,as owner of the property,or my employees with wages as their sok — STORIES TYPE CONSTRUCTION
mmpensatiz wuldo the work and the structure U not Intended or offered for
' O .1 (Sec.7044,Buslnnsand Profession,Code:The Contractors License Law
rig does not apply to an owner of property who Wilds or improves thereon,and
S^ whodoessuchworkhimselforthmugh hisown employees,provided that such OCC.CROUP RFS UNITS
improvements are not Intended oroffered for sak.If,howaveq the W ildingor TOTAL:
improvement is sold within ane ycarmfcmmp101oq the owner-builderwill have
th,c*aclm of proving that he did net Wild or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
IJ L as owner of the property,am exclusively conoxcang with limned FLOOD ZDNE APN
PERMIT ISSUANCE
outtractorslo ousleoct the project(See 70K Business a ad Professions Code:
-• The Contractor's Liana Law does nae apply to an owner of property who ALTER-DRAIN&VENT-WATER MM
Wilds or improves thereon, and who contracts for such ppicets with a
"q➢!(actor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under See, B&P C for this reason
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
RECEIFT N
}—� WORKMANCOMPENSATIONDECLARATION FD(.I.URES-PER TRAP SCHOOLTAX Y_ N
cal hereby affirm that 1 have a camficate of consent to elf-insure,or a RECEIPT N
certificate ofWorkers'Compesationlmurance or a certified copythemof(Sax.38M, GAS EA.SYSTEM-11NC.0 OUTLETS PARK FEE Y_ N
Polis Lab C.) RECEIPT
CaE Y ray GAS (E
EA.SYSTEM-OVER BU ILDING DI VI SION FE ES
Ca(Certified copy k hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy is filed with the city Inspection division.
CERTIFICATE OF U EMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recd t#
(This section need not b,completed tithe permit Ufor one hundred dollars
($IW)orlma.) WATER FIEA7'FR W/VENT/F2.FCTR ENERGY FEE Y_ N
m _
I rtify that In the performance of thework forwhlch this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTIN/.I.RFA77NG
Worken'Compensation Lawsof CalBamk.Date PAID
0 Z Applicant NEW RESIDENTIAL PCMB. QFf. Date ReCej tlf
Z NOTICE TO APPLICANT:Rm
after aking this Certificate of Exemption,you
H W should become subject to the Workers''Comper,ation provisions of the Labor TOTAL:
Code,you roust fort hwlth comply wilhauch provisions or this permit shall be BUILDING
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE Coo
CL o Ihereby affirm that there b a construction lending agency for the perform- ELECTRIC FEE
Zonce ofthe work for which this permit b Issued(Sec.3097,CIv.C.) TOTAL:
U O I<ndersName PLUMBING FEE
I- Lenders Add mv QTY. MECHANICAL PERMIT FEE
LL U Icertilythat l lave mad this application and statethatthe aboveinformatlortMECHANICAL FEE
0 W Is correct.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
). S relstingtobuildingconstruction,and hereby authorize reprcentatives ofthls
F N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDMMECH.
? (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Receipt#
V agabot liabilities,pdgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
`
against said City in eons once of ted granting of thUpertnit.
T/ AI
N R HANDLING UNIT(OVER 10,000IM
C ) CONSTRUCTION TAX
Ant can rat L� sDa/1—� FxHqusT MOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazzndom HEATING UMT(TO IW,000BTU) Date Recel til
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
flcelthand Safety Code Section25532(a)? HEATING UNIT(OVER I00,0W ITU) TOTAL: fit
❑ Yes M No
Miltheappliant or(uwmbuildingo pantumcquipmentordevicra VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous ab contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3FN OR 100,IXq BTU)
Ycs j�No
7havc reaclthat.Qous materials requ lmmcnts under Cha purr 6.95 of BOILER-COMP(OVER I(U"BTU)
the Celifomix health&S.(cry Code,Senior 25505,25533 and 25534.1
u nd aegis ad that if the Wilding does not ou rrently have a tenant,that it b my NEW RESIDENTIAL MECH. SQTT. 1(]f10
responsibility to notify the occupant of the requirements which most be met I JJ
prior to issuance of a Certificate of Onopanry.
Owner or authorized agent Data TOTAL: ISSUEDBY: j
OFFICE COPY