20538 APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification PERMIT NO.
Building 0 ress; 6 S M 2 5 20538
wnera ameaj1hone: p
�1,12� S'r`ft.6 N4M. CITY OF CUPERTINO-BUILDING DIVISION —7—'70EcausetofaN Lie N.: APPLICATION /PERMIT /
t BUILDING-E.FCTMCALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engiroer. Lil.No;
_^ ,A QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
\ Addrecs.Rg9 SARAYb" S�I PERMIT ISSUANCE �Q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Beamed under provisions of Chapter 9(commeuo- APPLIANCES.RESIDENTIAL JOB DESCRITION
ingwlth Sed1on7000)of Division3ofthe Buri u..nd Protenion.Code,andmy
Ilanse ie In full fora end died. PANELS
Clam Lich
D-to C 54 e/ -
Dale CantnctrolJ
ARCHITECT'S DECLARATION 7014000 AMPS
re0 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT. R AREA $/SQ.Fr.
Licensed Professional - EGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
H rat'3 1 h.mby.M.that Ism exempt from the Contractors License law forthe
7p Oppp following reason. 70715,Business and PmfmWns Code:An d or
ZF' county which requires a permit to construct,alter,improve,demolish,or repairTEM�WITTER OR PO EINST.
anystrudare prior to Its tesuance,'alw requires the appBcant for such permit to POWER D,
SkS
d file a signed statement that ha bs licensed pursuant to the provisions of the
Conlrador'.Lic...Law(Chapter 9(commencing with Section 7000)ofDivi. SWIM)OMpyECPRIC
X03 slon3ofthe Budnessand Profeuiora Code)orthatheleeumpttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUIL S FIXTURES
appllant fora permit subjects theappllcanl los civil penalty of rot mom than
ve❑I
m O fi ,unclmd dollars($SW). 1 -
'4.1 1,as owner of the property,or my employees with wages as their sole ` Al.ILFCTR_SQ.FT, STORIES TYPE CONSTRUCTION
compensation,wllldothe work.ancithestmcture is not Intended or offered for
O sale(Sec.7064,Buslrasa and Pedfesum s Code:The Contractors Lia Law
$ does not apply to an owner of property who builds or improve.the N rd OCC.GROUI' RES.UMTS
EE whodom such work himselfathrough his own employee.,provided th ch
improvements are not Intended forsaleve
.11,hower,lhebuildi
mTOTAL: _Q
improvementiswldwthlnoneyearofcompldlon,theownerbulWerwW e
the burden of proving that hedid not build orimprove for purposeofule.) PLUMBING PERMIT FEE FLOOD ZONE APN
u L a.owner of the property,am exclusively contracting with Ilan
crentredors to construct the project(See.70K Buslneasand Professors Cod : PERMIT ISSUANCE
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN k VENT•WATER(FA)
Wild.or tmpmves thereon,and who a mrarts for such pRojeds with a FEE SUMMARY
C7lB� k w
actor(a)licensed pursuant to the Contractors License Law. BAIX FLOW PROTECT'.DEVICE OUTSIDFFEFS
LJ I am exempt under Sec. B P C for this rean
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FTKFURES SCI100L TAX Y N
❑I hereby affirm that 1 have a certificate of consent to opy thereof
ora RECE11'r N
3800,anifLeb atWorkcri Compensatlonlnsurana ora adlfled copy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARKFEE Y N
3800,Lah CJ
PollryN GAS FA.SYSTIM-OVER 4I A) RECEIPT#
Co�mpany BUILDING DIVISION FEES
I .ICertNed copybhereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHL•CK FEE
RBF�,�kf'r'.'erilfled copy is filed with the city Wpe tion division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissedion need not be completed if the Permit V intone hundred doilars SEWER-SANITARY-STORM EA.IOatT. Date Recei t#
(g10cert leu.) WATER HEATER W/VENT•/ETDCTR ENERGY FEE Y N.
lllnot thato an rmananan the week for whichthis permit Is to
—
I shall not employ any person in any manner at u to become nrb)at to the WATER SYSTEM/TREATING
Workare'Compewtlon laws o(GWornta. Date PAID
-
Z Z Applicant NEW RESIDENTIAL TIME. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after nuking l his Certificate of Exempllon,you
should become subject to the Workers'Compensation pmvlsloru of the Labor TOTAL:
N Cade,you must forthwith comply with such provisions or this permit shall be BUILDING
W > deemed revoked. FEE
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrmthat there isa construction lending agency for the pedorm- ELECTRIC FEE
D Z xeceof the work for which this permit lslssued(Sec.3097,CIv.C.) TOTAL:
IJ O Lenders Name - PLUMBING FEE
LL h Lender.Addmu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythat I haveread this application and statethat lheabove Information
CL hcorreet.l agree to complywlth all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hcmbyauthodm representatives of this
Z dtytoenterupontMabove-mentio rdpmNayfm Wpedianpurposes. ALTER OR ADDTOMECH. Date Recei t#
L.I (We)agree to save,Indemody an d keep barrettes the City of Cupertino P
again, battles,Judgments,nestsand expenseswhlch may In anyway accrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
ag I itynsequense of the granting d this permit.
—� 40 AIR HANDLING UNIT OVER 10,000CFM) CONSTRUCTION TAX
na[ureaf Plant antra a a Dale EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplie"morfututs building occupant atom or handle hazardous HEATING UMT(TO 100,W0BTU)
mDate Recei [#
aterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Code Se Jloon 75537(a)T HEATING UNIT(OVER 100,000 BTU)- TOTAL:
Nlllthe applicanto�tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS JJ MDATE
whichemit hazardous air contaminants as defined by the Bay Area Air - f ((1�
Quality Management Distrld7 BOILER-COMP PIN OR 100,000 BTU) �Va•1 U71990
4Yee ❑Na
havereadth.haaa materialsrequiremenliunderChapier6.95of BOILER-COMP(OVER 100,ODO BTU)
the California Health k SrtetyCode,Sections 75505,75533 and 25534.I
understand that lithe building does notcunenlly have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT. Na ,�yy,,
raporsi 117 I.entify the occupant of the requirements which mud be met w)N OI CIIpeFY00
OdorS y�ndaCer�te ofI�AAta_. !o-'r9D
erorauthodaed nt Date TOTAL: ISSUED BI
OFFICE COPY