22841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PkBiMI'T NO.
Building Address: n f"I n /� 1
v' G G 7V5!TI
wn ra ante: orae:
CITY OF CUPERTINO-BUILDING DIVISION `� -
COnt.dor''Name. Lie.No: APPLICATION / PERMIT
&Z c e 3 VG 3C i BUILDINGELECTRICAI.PI.UMBINGMMIUNICAL CA9FOORY CONTROL x
Architect/ gineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 11�o/icAptne• C( PERMIT ISSUANCE ❑ ❑ ❑ T�
LICF.NSEOCONTR under rDECLARATION SS%1
I hereby a..70that lam.I.rn3 fth.Bu immannsot Cssiws 9(commrn AI'PEANCESRF9DENTIAL JOB DESCRUMON
Inensci I Hon force and efloon3o(the Bucineseand Pmleaalone Code,and my '
license le In full farce and dfect. PANES UP TO 2DOAbMS { `-�
LlcenecCVs x b G /
_Gantattor_ _/1_FATION L_L'ea
ARCHITECTSpAC public
PER 1000 PS
M _
q�uQO Iundentand my plane shall be used upublic reomds. OVER IOW AMPS SQ.FT.FLOOR AREA 3/SQ.Ff.
kX Licensed Professional - SIGNSELECTRICAL ' N
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC E R
Z. 4 Iherebya(Rrm thatI am exempt from the Contractors License Law for the
Z following reason. 70315,Business and Profession.Code:Any city or
O4 TEMP.METEtORPOLEIN
�E anystm=ntympti lois ancealsonuimatheapUmntfrwch, er itr ^ease �as�
�§ .a ale A signed res orlo a that a is,Ii.Aso pursuant t the provisions
of the IX)W'F.R DEVICES DATE
!�
y'a � Nle a signed statement That he V Ilcenxd pursuant to the provAlonu of the
3µ'i+ Contractor'sLicense Law(Chapter 9(comumcurg with Section 7000)of Divi. SWIMMING POOL ELECTRIC
SOS sion 3 ofthe Buslnessand Professions Code)orthat he be exempt therefromand VALUATION
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXTURES
applicant for a permit.ubjectn the applicant to a civil penalty of net momthan
five hundred delta.(500). NEW RESIDENTIAL ELECTR
�n ❑1,as owner of the property,or my employees with wages as their auto NEW STORIES TYPE CONSTRICTION
compensation,will do the work,and the structure Is nm Intended or offered for
q sale(Sce,7614,Business and Prf.iiona Code:The Contractor.Lt..law
�$ does not apply to an owner of property who Wilde or improves t homer,and
who doeeauch work himselforthrough hisown employees,provided that each - OCCGROIIP RFS AMTS
Improvements are not Intended oroffered!create.If,however,thebullding or TOTAL:
improvement baold withinoneyearofcompledon,the owner-bullderwlll have
�
th, urden of proving that he did nm build or bnprow for purpow c(ile.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN .
u L as owner of the property,am exclusively contracting with licensed ppRMITI�IIANCE
contractors to conatmd the pmjed(Sec.7044,Business and Professions Code:
The Contndors License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such p(ajetls with a ALTER-DRAIN&VENT-WATER(EA)
.dafactor(s)Horned pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L j I am exempt under Sec B& P C for this reconOUTSIDEFFES
OwnerDRAINS FLOOR ROOF,AREA,OOND. SANITARY Y N
Date RECEIPT N
WORKMAN I haw a )SATIONDECLARATION FNTURpS PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a l H ran of consent to pythearc,ora RECEIFr#
certiBale of Workeri Compsnsation]vurancemacertllled copy lhercof(Sec. GAS'EA.SYSTEM-1 INC40UILETS PARK FEE Y N
3800,lab C.I
Poliryx qwC907�. S.i;n GAS-RA.SYSTEM.OVER4(EA) DINGRECEDIVISION
Cam BUILDING p1VIS10N FEES
lCertiOed copy b heed with hecit. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
17CertVied copy b riled with tM city inspection division.K' CERTIFICATE OF FXEMPFION FROM WORKERS' GREASE TRAP PAIDCOMPENSATION INSURANCE
(Hossedlonneed nor be completed Bthepermlt isforonehundrad dollars SEWER-SANITARY-STORM EA.200FT. Date Receipt#
(5100)arfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icenot thatlnthe person
]manhe ner an as t ch cornhis wbjermit Owed, —
I shall not employ any person In any manner at u to become abject to the WATER SYSTEM/TREATING
Workeri Compensation Taws of California Date PAI D
O Z NOTICE
rat
NONEW RESIDENTIAL PLMB. SQ rr. Date Recel t#
Z O Applicant
MPLICAM:IL ocher making this Certificate of Exemption,you
Hshmldbecomewbja tothe Worken'Campsmatlon provblonaofthe Labor TOTAL:
= N Code,you=at forthwith comply with such provisions or this permit shall be
W j deemed revoked. BUILDING FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I lumby.111that there's a construction lending agency for the perform ELECTRIC FEE
D Z ance of the workfor which this permit is Owed(Sec 3097,Civ.Q TOTAL:
V Oenders Name PLUMBING FEE
LL ~ Lender',Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W r'
1 mdBythatl have read this applialionand statethat theabove Information
S :s Correct.I agnmto complywlth all city and county ordinance.and state lave PERMIT ISSUANCE , a FEES
} N relating to building construction,and hereby authorize mpresentatlers of this
F— m
city to enter upon the Above- entloned property for inspection purposes. ALTERORADDTOMFCH.
Z I#
V Z (We)agree to save,IndemDate Recei '
county an d keep harmless the City of Cupertino F
again e60 les,judgments,coet.and expenseewhlch mayln anywayaceme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
wt said ty low a sen a granting of(his permit.
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Ig..wApplleent/Conr Da ExHAf15THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD tract MATERIALSDISCLOSURE
Will the applicant orfuwm building oc%quntstoreor handle hazardous HEATING UNIT(TO 100,000 BTU) 9 Date RCCelpt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,007 BTUI TOTAL:
Yee No
Will the applicant or lure bulldingompanl see equlprrcnt ordevlcea VFN'RLATION PAN(SINGLE RESIU) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air p P
Quality Management Dlstdtl7 BOR,IiR-COMP(3kE'ORIW,ONBTU) PAID
Yes 5o
have read the haza`res materials requlremenOunderChapter6.95 of BOILER.COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1O �(I/T
understand that lithe building does not currently have a tenant,that it is my NEWRESIDFNTIALMECH. SQ.F I. NOVIY B x7
responsy Anetify the oc At of the requimmentawh lch must be rrct
A lssua sofa of Ocwpancy.
CI I r QF CUPEHTU
Own rauthodrad ogcf Date
TOTAL: 155000 BY.—
OFFICE COPY