21572 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro'en Identification PERMITNO.
Building Address: 6y �� 9 �� 21572
-76 ( A/ CYma� oe:VWV Cu w
u w'f E Y b' A 63136-f�-% CITY OF CUPERTINO-BUILDING DIVISION A
Contractor's Name: Lle.No: APPLICATION /PERMIT `2�`-7_q0
BULDINGFLECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROL x
Architect/Engleact: Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE LZ Cz y INTI ❑ 9
LICENSED CONTR under provisions
LJ LJ
T hereby affirmthatlamlken3ofthe usine andP ffe amsr de,and(conamene.
my APPLIANCFSRESIDENTIAL � JOB DESCRIPTION
IngwehSttHon 7000 ofd efeon3o(1he Bualneseand Proleulona Code,and my t,"1 W i�-FOcta.I�
Licar s is hi full force and it N PANELS L+ ,
Datc ClassCort C'i FR►�S �
Date Contractor 1"? 'T
ARCHITECTS DECLARATION 00 AMPS
�Z I understand my phns shag be ueN m public recoil.. OVEROVER]000 AMT'S SQ.FP.FLOOR AREA 4/SQ.FT.
CO
(1 Licensed Perfeagoal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION 11
7, Iherebyaffireathal l am exempt fthe Contractor's License Law for the L SPECULCIl2CUT/M6C
6Zrq rom
following remon.(Section 7031.5,Business and Professions Code:Any city or TEMP,METER OR POLE INST.
u3 county which requirma permit lomnawct,alter,Improve,demolish,orrepair
Y5.9 anystrunure prim to Its Wuance,also requlrestheappllcant forsuch permit to POWER DEVICES
K`V file a signed statement that he b licensed pursuant to the provisions of the
Ou, Contractor's Llceme Law(Chapter9(commenciagwith Section 7000)of Divi- SWINMING POOL ELECTRIC
yyy.��30C' sion3ofthe Bugnmsand ProfessionsCode)orthat he is exempt therefromand VALUATION
the bash for the a11egM exemption. Any vioiatlon of Smbn 7a3I.S by any ` OUTLET5-SWITC) FIXTURES Z,0(nC3 a W
6Qa
applicant fort perMtsubjemstheapplicanttoadvil pensityofnotmenethan
getc fve hundred dollars(5500. NEW D ALE ECTR SQ.FT. STORIES TYPE CONSTRICTION
�, ❑1,as owner of the property,or my employees with wages as their sole
t,7¢ compensatlon,willdothe work andthestructum is nes intended or offered for
$ O sale(Sec.7M4,Business and Professions Code:The Contractor's Llceme Law
S$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself orlhrough his own employees,provided that inch
impmvemenbarenotintendMorofferedfors k.If,howevegthebulldingor TOTAL: 00
Improvement bsold withinoneyearofcompl&ion,the owner-builderwill have
grdenof proving that hedld nor Wild or improve for purpose ofsale.). QTY. L 13ING IT FEE FLOOD ZONE APN
ere owner of the property,am exclusively contracting with Iirensed PERMIT SSUA
interests to construct the project(Sec 7044 Business and Professions Code:
The Contactor'.Llcenx law doee,not apply to an owner of property who
Wild.or Improve themor4 and who contracts for such pte)ects with a ALTER-D & -WA (EA)
cQ02factor(s)Ilcamed pursuant to the Contractor's License Law. BACK FLA) T. E FEE SUMMARY
u I am exempt under Sec. B&P C for this reason '
DRAT R R r REA COND. SANITARY Y_ N
• Owner Date RFOFR'1'a
WORK MAN COMPENSATION DECLARATION p� SUTOOL TAX Y_ N_
❑1 hereby affirm that I have a Insurance,
of consent to op thrum,(Sa RECEITT N
wrtlfiate ofWorkera Compensatlonlnsurancewacertifkd copy lhereo((Sac. .t INCd OUTLETS PARK FEE Y N
3800,Lab C.) —
Pollcy a RECEIPT p
Com say AS EA.SYSTFhf-0VER4(FA) BUI LDING DI VI SION FEES
❑pCcrtlfied copy is hereby furnished. CREASE/INDUSIRL WASTT:INTFRCEPTOR PLANCHECICFEE
71 Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1. Date Recei t#
ffhissection need not W completed tithe permit b for one hundred dollars
(a10(forlem.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 unify that In the performance of the work forwhlch this permit Is lasted,
I shall not employ any person In any manner so a to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Callfornb.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ.ET. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provislons of the Labor TOTAL:
f N Cade,you must forthwith comply with such provisions or this permit shall be BUILDING FEE IL4. 100
� j deemed revoked.
IL mCONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihembyeffirm mw
that there is a mndion lendingagency forthe perform TOTAL: ELECTRIC FEE c($
7 Z an..ftht work for whichthb permit is Issued(Sec.3097,CIv.C.) PLUMBING FEE
U O Leader'.N.mn
LL F- Lander'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 00
U lartifylhat l haveread this application and statethatthe above information ^� /fir
0 W burmn.I dgme to comply with all city and county ordinances N
and gate laws I PE4MITISSUACE 1_1 ZO FEES PAID:
Y
it. relating tobealdlogeomtruction,and hereby authorize repremetativesofthis ^ ^�
F Z cityto enter upon the abovc.nrmtbned property for Inspection purposes. ALTERORADDTOMECH. GsW
_ Date Receipt#
(We)agree to save,Indemnify an d keep es whitharmless the City of Cupertino AIR FIANDLING UNIT OO10,000CFM)
U aga1mt11ab11itkts,}Idgmenb,"sand expenses which may In anywayamue SUBTOTAL:
.galyin enryuencpoff anti oithis permit. CONSTRUCTION TAX
j^�� ') AIR FiANDWNG IIMT(OVFR IO,WOCFMI
gg(w_ttureoof AppBesud,Cjontratlo\r VL -oma t—C•• a) EXHAUSTIIOOD(NI DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pphn nt orfuture building occupant store or hand It hazardous BEATING UNIT(TO 100,000BTU) Date Recei t#
material as defied by the Cu pertlno Municipal Code,Chapter 9.12,and the
lialth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU TOTAL: aS
C-]] Ycs M No
Will the applicant or future building occupant use equipment or devices `Z VENTILATION FAN(SINGLE RFSID) 4� ISSUANCE DATE
which emit hazardous air contamlants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,0W BTU
❑Y No
Ihavcread the haza�ua materials requiremant,under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU) 0Q
the Califemla Health&SafetyCode,Sections 25505,25533 and 75534.I �'!�
understand that lithe building does not currently have.tenant,that It is my NEW RESIDENTIAL MEIN. SQ.FT.
responsibility to notify the occupant of the requirements which most be mel 1•+ p{',�, a ��e(Ti /'��
prior to Issuance of a Certificate of Occu pa ncy.
Owner or authorized agent Data TOTAL: (7) ISSUED
OFFICE COPY