20612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address:
Zs5'1 lqo l zg4 r. Coo. 20612
nere ams: one:
CITY OF CUPERTINOQBUILDING DIVISION
,loiName: Li.N°: APPLICATION /PERMIT l�
BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL`C_
gineer. LI.Na t�QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
z /
Address: D AR J/; PERb11TISSUANCE tQfl
uL� III I'llivo MI"
LICENSED CACTOR'S DECLARATION
I herebyion700OWDleSoon that I am llcmsed older
Businessions
I'mChapnr sions9(commme- APPLIANCFSRESIDENDAL OB DESCRB''FION
Ingwlth5ectlon 7000)o(d effism3o(the Buelnessand Pro eastomCmde,and my
license lain full roe and e.0 PANELS
LiceDate Clam Uc.N
Dale Gontl•dar UPTO2D0A1s,[PS R'TpJ`IJl t AJl/
ARCHITECTSDECI.ARATION 701-1000 AMPS
q�q�vv aO Zp I understand my plane shag be used as public monde. OVER 1000 AMPS4TOTTAL:
SQ.FT.FLOOR AREA $/SQ.FT.
k (Oj LicensedProfeeslorul SIGNS ELECTRICALProof 4,40 �ie9'Z
<6 OWNER-BUILDER DECLARATION SPECIAL CIRC L
z Ihereby affirm that am exempt from the Contractor's License law for the2EiKA9� 3So 51(7
O 2..p following reason.(Section 70315,Business and Professions Code:Any city or TEMP METER R 'J
p tu�Jl countywhich requires a permittomwtmR,alter,improve,demollsh,orrepalr
anystm=mpriotolblaeuance,alaorequimatheappllantfor•uchpemdtto POWERD
�K file a signed statement that he Is licensed pursuant to the provisions of the
Ou, Contractor's License Law(Chapter 9(commencingwRhSeR1on70M)ofDlvl-
1.,'30 sirn3o(the Buelnese and Professions Code)arthat helaexempttherefromand SWIMMING POOLVALUATION
$' the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fare Ferrell subjects the applicant to a civil penalty of not morethan OITILEISSWIfive hundred dollars($SM. NEW RESIpENTIAL EL�I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
compensation,w91 do the work,and themmcture la na intended or offered for
0sale(Sec.7044,Business and Professions Code:The Contractor's License Law
does not apply tom owner of property who builds or Improves thereon,andOCC.GAOIRr RFS.UNI75
who doeesuchwmrk himself orthrough his own employees,provided that suchImprovements are not Intended or offered for sale.If,however,the building or
Improvement is sold within one yeamf compietion,the owner-but W erwlll have
'th,R*rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed pE2N1T ISSUANCE 1
contractors to construct the project(Sec 7044,Bustnen end Pro(esslors Code: l{t
The Contractor's License law does not apply to an owner of property who ALTERDRAIN&VENT WATER(EN
budds or Improves thereon,and who contracts for such plajeds with a FEE SUMMARY
o9aflactor(s)llcenaed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec B&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RFGEB'[N
K
'�
❑I hereby affirm that I have a certificate of consent to self-insurel FIXTURES PER TRAP SCHOOL TAX Y N
,or RF-CEITT N
certificate of Workers'Compensatlonlexurance or•certified copy thereof(Sec GAS EA SYSTEM-1 INC4OUTLETS PARK FEE Y N
380),Lab C.)
Policy GAS EA.SYSTEM-0OVER `� RECEIPT
Com any BUILDING DIVISION FEES
Certified copy la herebyfurnished.the city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cerif ed copy la filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID qt
COMPENSATION INSURANCE SEWEA- STORM EA.20071. Date Recei t#I l
(TNs eectlon need not he completed if the permit la forom hundred dollars
($100)orleas.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertifyihat NN
the performance ofthework(orwch this permit is blued,
I shall not employ any person In any manner no as to become subbed to the WATER SYSTEM/TREATING
O
Workers Compensation Laws of California.Date PAID
Z NOTICEApplicant $ .NEWRESIDENTIALPLMBDate Recei t# 7VaW
Z O NOTICE TO APPLICANT.If, making this Certificate o(Exemptlon,you SQ1,F. v3
Fshould become subject to the Workem'Compemallon provisions of the Labor TOTAL: 7.0
W Code,you moat forthwith comply with such provisions orthis permit shall be
s
60
d j deemed revoked.CONSTRUCTION LENDING AGENCY BUILD N-G.FEE 5"f SEISMIC FEE s
I hereby affimnthat there is a construction lending agency forthe perform- t
Z aam mfthe work for which this permit is L E
lamet(Sec.3097,Civ.C.) TO ELECTRIC ECTRIC FEEEE (()O
V O Lenders Name
LLF- LendereAddress QTY. MECHANICAL PERM IT FEE MECHANICAL FEE
O W, Icerilfythatl have madthi•appllutlonand statethatmeabove information MECHANICAL
C bcormet.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE 2y�� FEES PAID:
�. relating to building construction,and hereby authotlze representatives of this
F Z city to enter upon the above-mentioned properly for inspection purposes. t ALTER OR ADD TO MFCH. 21 Cd7
(We)agree to sews,Indemnify an d keep harmless the City of Cupertino Date Rxeipt#
V against liabilities,judgments,.4.and expense.which may in anyweye,=. AIR HANDLING UNIT Fro 8000 CFM) SUBTOTAL:
ag.1 sold Ci Inm a e mfthe granting of this permit AIR HANDLING 11fYTC(OVER l0,000CFM) CONSTRUCTION TAX
Signature of pplican/Cors m or OsI. EXHAUST FLOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store of handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Safety Code cilon 75532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
n Yes No
Bl the applicant tore building occupant use equipment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
whichenotharardou airmntaMmntsasde0nedbylhe Bay Area Alr
Quality Management Dist 7 BOILER-COMP QHP OR 100000 BTU) X11"
;ave
o. 1 1
"['have read the haza ouamateriala requlremente under Chapter 495 of BOILER-COMP(OVER 100,000 BTU)
the Califomla Health&Safety Code,Sedimns 25505,75533 and 25534. I a
understand that lithe building does not currently have a tenant.that it b my NEWRESIDENUALMECH SQ.FT. X'�ri{'f PI(s•IngrtlDf)
responsibility to notify the occupant of the requirements which must be mel I
prior to Issuance o(a i ute of Occupancy.
C
or aulh ent ^2 ate Q ISSUEDBY;
TOTAL: TWIMY
OFFICE COPY