20947 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pouted Identification TNO.
%doff Add m.; c.� 20947
9 I
Hers .me' one: AllitlICA11ON SUB."ME=
E]�(7 o: v-2` 6
CITY OF CUPERTINO-BUILDING '
Lie.No: APPLICATION / PERMIT
L J� BUILDINGELECMCALePLUMBINC-MECHANICAL CATEGORY CONTROLN
Arehltect/Engineer. Lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: .
PERMITISSUANCE ' ❑ ❑ - ❑
Lmthat EDCONTRt order rOECns RATIo(ChONGG - � 7O
T We
Ihereby
iOA70lhrtlam Remnant order APPLIANCESRESI)ENfIAL J�3 1 nU'
im.1 Sect1on7000)of DlWslon3ofthe Butlnenmd ProleWaneC.de,mdm /
:cense b in(u d d(ect. � PANELS"en Ian Lk:N
ale mdra or_ 201-1 AMPS
ARCHITECT'S DECLARATION
NO 7.7 •,�Iundemm�d my pia shaBbe used m pubic recordeM OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
q� O
k� Licensed Profenlanal T SIGNS E CAL -
<�"a OWNER-B ER DECLARATION SVI;CIALCIRC
Ihereby afRrm that i am exempt from the Com rectoe.LlcennlaW forthe
roilowing reason.(Section 7011,5,Business and Profeulone Code:Any d or
02
mantywhich requlresa permit toconstme,alter,Improve,demolbh,or repair
ture
anystnecpdnrto lbbeaance,obo mqultestheapplimat for such permit to IO D
tA
O Rle a signed statement that he Is licensed pursuant to the provbloru of the
�µ Contrecon's Limneelaw(Chapter9(commencingwith Snoi..700(ftof DIri- LELE
elon3ofthe BusinmemdProfmn mCode)orthathebexemptthemfmmandCIAC� VALUATION
the basis for the alleged exemption. Any violaHan or Section 7011S by any OUTLETS T'CHFS
applicant fora permit wblecbthe applicanito a dvll pemltydoor mere than
fi
n, b ndreddollam(N500).nNEWR ENTIAL ELECTR
I,as owner of the property,or my employees with wages as their wk SQTT' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure isnot Intended or offered for
O nit(See.7074,Business and Prorenlom Cade:The Contractor,Lim.law
�$ don not apply to an owner of preperty who builds or Improves thereon,and OCC.CROUP RFS UNI75
who docasu=h work himself orthrough his own employees,provided that each
impeovemenb arc not Intended oroffered forsale.If,however,thebuilding or TOTAL: -
ImprovemnnibwldwlthlnaneyearofcompletioNthe owner bulWerwlllhave
llm,Lurden of proving that he did not build or Improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE . FLOOD ZONE APN
L_I 1,
A.
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �7 p.
comoutere to construct the prokct(Sec 7614,Business and Peo esslum Code: ay
The Contractor's License Law don not apply to An owner of property who ALTER-DRAIN QVENT-WATER(EA)
builds or Improves thereon,and who contracts for plect
such tas with a (�
ryIl[f+ctor(s)B.nrd pursuant o the Contnctota Ll.nse Law. - FEE SUMMARY
Li I am mempt under Sec B 4 P C for thh reawn BACK FLOW PROTECT.DEVICE OUTSIDE
tpwner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEI T N
WORKMAN COMPENSATION DECLARATION FINTURF_S-PER TRAP SCHOOLTAX Y N
I hereby affirm that I have a certificate of monism to selPinwre,w a RFCEfIT N
rtD,Lab (verkere Compensatl.n Imuran.ma ceufled copy theroo((9ec. GAS EA.SYSTEM-I INCA OUTLETS PARKFEE Y N
3800,lab CJ
Policy N GAS EA.SYSIGI.OVER 4(EA) RECEIPT N
Com any- BUILDING DIVISION FEES
MCertlfled copy b heed with:'shed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE -'
F Certlfled copy b riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20081. Date Recei t#
( eectlon need Hct b completed lithe permit b forone M1undred dollars
(f100)3)mlen.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertifythat In the performance of thework(arwmchthle permit is Issued, —
I shall not employ any person In any manner An,as to become subject to the WA.ypg gySTEM/TREATING
Workers'Compensation Laws of California. Date - PAID
Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,ober making this Certificate of Exemption,you
N should becamesubject to the W.rlum'C.mperuatlon provbWns orthe Labor �av�-,� L TOTAL:
me
Code,you at forthwith comply with such provisions orthb permit shall be I-�'\F9Jlt)A/�Ii, � BUILDING
W > deemed revoked.
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aorkfo at which
re b e permit
i construction d ding(Sec. agency Cls. .) perform, TOTAL: `� ELECTRIC FEE
Z ance of Lerderthew.rk(orwhkhthb perMtia issued(Sec.3097,Civ.C.)
V O Lender's Names PLUMBING FEE
IL F Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read thbappBntionand statethat:healsmelnformatime
O. bcorrect.lagrreto comply wkh.11 cltyand muntymcknanees and gate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authodm representatives.(this
[— Z citytoemeruponthe abovcmemluned propertyfor Inspection purposes. ALTER OR ADDTOMECH.
Z a gree to save,tndemnl%and keep armless the Clty of Cupertlw Date Receipt#
Inst ablCity,jadgmenb,costeand en a bleb maylnef en may enyw�e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:-
A I Aida l said-CA,cgpeequ.n�( he est o his pe the est o hh pa t.
l�^J Opp AIR HANDLING UNIT(OVER t0,000CFM) CONSTRUCTION TAX
Sigmtureor pant/Contcactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
IAIARDOUS MATERIALS DISCLOSURE
Will the ap morfuture building occupant store or handle hazardous HEATING UNIT(TO 106,000 BTU[ Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes , MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
ggrrrr which emit hazardmn.I,contamlrunteas defined bythe Bay Area Air
+' V ` Quality Management District? BOILER-COMP DFO'DR 16QOfD RTU)
Q(''''�Yn ❑No
s%_ii have reaA the hazardous materials requlremenb undcrChapler 6.95 of MOILER.COMP(OVER100,000BTT7)
,he California Health k Safety Code,Sections 25505,25533 and 25534.1
tom,/ understand that it the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
naponlblllty to notify the occupant of the requirements which moat be mat b y ,gen
pr Wbwanceofa CedifkateofOccupancy. �7(/
Owner or auth.nmd agent Date
TOTAL: ISSUED BY:
OFFICE,COPY