20981 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Idemlflation PERMIT NO.
Build�Address: / 20981
AITU�IIUN bUBMI1 IAL DA IE
nee. came: ant:
Iyd CITY OF CUPERTINO-BUILDING DIVISION o
Cc f, ctore me: s Lie.Na APPLICATION /PERMIT
w a BUILDING-ELECTRICAIPLUMBING.MECIIAMCAL CATEGORY CONTROL N
AM,
hl `/Enginaer. Llc.No:
BUILDING PERMIT INFO
4TY ELECTRIC PERMIT "FET:
AddressPERMITISSUANCE ❑ El ® ❑
' LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provLdonsofChapter 9(commenc, APPLIANCESRESIDENIIAL. JOB DESCHEFHON
Ing with Section 700D)of Division 3oflhe Business and ProfessionsCode,and m � �;T"C
license Is In fun f and effect. -.j/ PANELS
Li=CI..-�Lic.I' (p� -
Date ContractorUP TO 2DOAK�S
ARCHITECTS DECLARATION 211-1000 AMPS
q0Z I understand my pew atoll he used u public remrde
OO OVER 70W AMPS , SQ.F r.FLOOR AREA $/SQ.FT.
bi Licensed Professional SIGNSELECTRICAL ,
<<< OWNER-BUILDER DECLARATION
fn]a SPECIAL CIRCUIT/MISC
Cyt-'YA I hercbyafRrm
that I exemptGILDER
E LARATIO License law for the _
OR— following mature.(Section 7ml S,Business and Professions Coda My city or O Z TEMP.MEITR OR POLE INST. '
Py county which requbaapenNt lomvMuQ alter,Improve,demolish,orrepalr
a nystmmmpMrwitaimancealwrequimetheappha tforsuch Fwr tto POWER DEVICES
file a signed statement that he is Ikxved pursuant to the provlalov of the
Ow Contractors Lfc...Law(Chapter9(mmmencingwlthSeRion7000)ofINA-
30 slon3aflhe Buelnessend Prfessl.vCode)orthalhei.exempttherefromand SWIMMING POOL ELECTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7071.5 by any OUILE7SSWITCIiESFIXTURIS'
applicant fora permit subjects the applicant to a dvll penalty of no more than
flue hundred dopers($po. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONS'IRUCI'ION
000 �n ❑I,as owner of the property,or my employees with wages r offered
sole
compensation,Buldothe wokand thes Code.
is The
tntaMcd cava mLfor
D sae(Ser,apply to an ow and f premlov Code:The Contractors Ueeve Law
does not apply to an ower of property who builds or Improvesded t at and OCC.GROUP RES.UNITS
who ovessuchwc e'himself alhrough hlsawn employees,provided Thal such
improvementsarenaintended!orofferedtorula.If,however, deer ill have TOTAL:
Improvement bwld within onayearolcomplctlaR lhtowner-bunderwlll have
t rden of proving that he did notbulldorimperveforpurposeafuleJ. 4[y, PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE, - •�
contracture to construct the pmject(Sec.7074 Business and Professions Code:
'Me e Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER
builds or Improves thereon, and,who contracts for such piooms with a FEE SUMMARY
�gp((�dorW hansed pursuant to the Contractors License Law. BACK FIAWPROTECT.DEVICE
Lf I am exempt under Sec B&P C for this reason
QIITqInP FEES
Owner Date
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT If
by af(bm t
WOAg11AN COMPENSATION DECLARATION FIX7lIRES PER IRM SCHOOL TAX Y_ N_
pl herehat I have a cerHRate of content to sen-Insure,or a N
MOO,arti �b at,C) S of Workers'Compevatlonlvunnce ora certifiedcertified copy lhemo!(Sec. RECEIPT
GAFA.SYSTEM.1 INC4 OUTLETS eZp� PARK FEE Y_ N
Paltry N RECEIPT M
Comny GAS EA.SYSEMAVER 6(FA)
BUILDING DIVISION FEES
Cified copy Is hereby furnished.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b toed withhthe c
e city inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 2OF1' Date Recel tN
(This section need not be compiled Ifthpermitpedt Vfw n one hundred dollars
(s100)aressses.)3 - - WATER HEATER W/VFNI'/E.ECTR ENERGY FEE Y N
I certify emplt in oy
heperformanceollhewok so as towhich co permit is blued, —
I tins II no employ onr•person f any manner at u to become subject to the WATER SYSTEM/7RFATING
Worken'Compenaation Laws of Gn(omla. Data PAID
Z Applicant - - NEW RESIDENTIAL PLMB._SQ.FT. Date Receipt
Z Z NOTICE TO APPLICAM:U,after making this Certificate of Exemption,you
Fshould become subject to the Workers''Compevallon provisions of the Labor TOTAL:
� N Code,you must forthwith comply with such provisions or this permit shall be
1 deemed revoked.
dCONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby alBrmthat there We covtroction lendingagenry for the pedorm� ELECTRIC FEE
M Z ante olthe work for which this permit is issued(See 3097,Civ.C.) - TOTAL: L�j
02 I<ndert Name - PLUMBING FEE
IL I- Lendeea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlly Mat I have readthlsappuatimaM xt.athaltheabove lnlomatlan -
bcorred.I agree to comply with all city and county ordinances and rate laws PERM17ISSUANCE FEES PAID
} 4 mlatingtobullding construction,and hereby authabco repreacntativv ofthis
I_ N Ldty enter upon the sbovcmenlioned property fee Wpedlon purposes. ALTEIORADDTOMECH. � -
Ze)ageetosave•indemnl/yand keep harmiess the City of CupertinoDate ReCel tN
lllabiut judgments,comm xper..whTc In enywayaaxue AIR HANDONG UNIT(f010,W0 CFM) SUBTOTAL:
t sold tyle eryu a grantirg of t p IdLy �j�
I��-Ll1 AIRHANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
'Ig re Applicant tr - I Date �U1 IXHAUST HOOD IW/DI1C7) CONSTRUCTION TAX PAID:
HA DO MATERIALS DISCLOSURE
Wil the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IM,000 BTU) Date Revel tq
material as doll red by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety CgQe,S9ptlon 25532(a)7 HEATING UNIT(OVER 10),000 BTU) TOTAL:
❑Ya , o
Will the applicant a mm building occupant use equipment or devices VENTILATION PAN(SINGLE REED) Cp ft*DATE
®
which emi...gemoueatrcontaminants as de0ned by the Bay Area Air �G/
qu�yManagement DL+Mct7 BOILER-COMP pFm OR 100,000 BTU) Ga •)O9�
Yce o V +y�
nae mad tfie haze ow material.requirements under Chapter 6.95 of BOILER-COMP(OVEi 100,000 BTU)
the California Health&SafetyCode,Sedtona 2550$,25533 and 25534.1
understand that if the building does not currently have tenant,that it is NBWRFSIDENHALMECH. SQ.FT alk Of DDft}
roponalbulty to dilytheoccupant fthe requ[m a ll"h must be and "'e`r'+✓UdY
priortolau,n orfs 10camupanry.
-G-gct61yyeaxEx
ner out rind age Data ISSUED BY:
TOTAL:
OFFICE COPY