20971 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
7'Hunding Pra'ect identification - PERMIT NO.
Building Address: J 20971
ero one. - p
' n " CITY OF CUPERTINO-BUILDING DIVISION
onrsdarPERMIT '
Cs a APPLICATION)PERMIT '
S QtD� BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROLN
Arch teR glneer: Llc.No:
(� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrv. a, V�G PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commere APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
ingwlth Section 9000)o/DiWdon3 afthe Budneseand Pro/eslonsCode,and my
licensers in ful �orsyn effect. PANELS
License CU :' C ,#_ GI n 3f-E
Dale Contractor �• 200AMPS
ARCHITECPS DECLARATIONAMPS
reZ ]understand my Plato shall be used upublicrecords OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZCO
� Licensed Professional SICNSELECTRICAL
Q'm OWNER-BUILDER DECLARATION
MI "Er3 SPECIALCRCIIIT/MISC
ns,�� I hereby affirm that]atm exempt from the Contractor's License law for the
following reason.LSectlan 9(315,Business and Profession.Code:My cityor
J Z FTEMP.METER Oft POLE INST.
M Psicountywhich requlreea pemdt tocorotruct,alter improve,demollsh,orrepalr
anystmmmpdortoltsl wancgaLs mqulrestheapplicentforsuchperMtto POWrERDEVICES - -
file a signed statement that he is licensed pursuant to the provisions of the
33 f Conmctor's Uterus,Law(Chapter 9(commencing with Section 7000).f Divl- SWIMMING IDOL ELECTRIC VALUAT ON
X05 sion3ofthe Bosinessand Professions Code)orthat heisexampt therefromand -
the basis for the alleged exemption. Any violation of Salon 7MI5 by any 'OUTLETSSWH'CHESFIX'NRES '
O appllcant(ora perMbubjects the applicanuaa civil penalty dnatrrorethan
live hundred delta.($500). NEW RESIDENTIAL ELECTR SQ.FT, TYPECONSTRUCTION
M ❑1,as owner of the property,or my employees with wages as Iheir sole
�ZQ compensation,will do the work and the structure in not intended or offered for _ '-
O sale(See.9044,Business and Pmfesions Code:The Contractors Licerue Law
does not apply to an owner of property who builds or improves thereon,and - - .GR011ls RES.UNITS
doessuchwork him lorthrough hlsownemployees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement Is sold with In one year ofcompletlon,the owner-bullderwill have
tlry�u rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with licensed FLOOD"LANE, APN
contract m to construct the project(Sec,9064,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
bulli,or Improves thereon,and who contracts far such projects with a ALTER-DRAIN&VENT-WATER&M
cgB�[achv(s)Ikemed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec B& P C for this reason BACK FLOW PROTECT.DEVICE
nily4l.t:ITV,
DRAINS FLOOR ROOF,AREA,COND.' SANITARY Y N
• Owner Date - RECEIPT#
WORKMAN COMPENSATION DECLARATION FUTURES-PER TRAP SCHOOLTAX Y N
cen
❑1 hereby affirm that I have a cersBranc of consent to opfdnsure,ora RECEIPT#
38MLate of Workers Comperwdonlrounnce orasrtl(kd copy thereof(Sec. GAS EA.SYSTFM-I INCA OUTLETS PARK FEE Y N
3800,Tab CJ RECEIPT N
Po11cyN W GAS EA.SYSTEM-0VFRd(EA)
Com crass NA
BUILDING DIVISION FEES
Certified copy 1,;hereby furnished. GREASE/INOUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division.. .
CERTIFICATEOFIXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCeI [#
' crhlssectlonneedndbecompldedlftMper tlsforonehundreddollars
(SIMI or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythat in the performance of the work for which this permit is bossed,
1 shall not employ any person in any manner se,as to became subject to the WATER SYSTIM/TREATING
Workers Compensation Laws of California.'Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ hT. Date RCCCI t#
Z O NOTICE TO APPLICANT.B,after making this Cedtflste of Exemption,you
should become subject to she Workers Compematlon pmvisiom of the Labor TOTAL:
cc N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE
W > dMmed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a O eof th workf h.tfor
them bacorewctlsu minding ,Ci.C.) perform ELECTRIC FEE
7 Z orue
ce of the work(ear which this perM[bbwed(Sec.3099,Cie. TOTAL:
(� O Lenders Name - PLUMBING FEE
F Lenders Addmas QTY. MECHANICAL PERMIT FEE
O W lsrtify that l have read thisappllntlon and date that the above infm
oration MECHANICAL FEE
S mored.I agerem comply with al cilyand county ordinances and date laws PERMIT ISSUANCE IZ42PEES PAID: .
} relatingrobuildingearstrudse
lon,and herebyautho m,representatives ofthis '
I•" W city toenterupon the aba,mcntloned property for Inspection purposes. ALTERORADDTOMECH,
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V agaWtBabiBRo,pdgmens,`tsand exile awhich may In am w amus, AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agate City isnsryur o egra efthispermit AIR HANDLING IINIT(OVER IQODO CFM) CONSTRUCTION TAX :
nate Applicant/Conlracior to IX}IpI15THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSU E
WII eappliant or future building occupant store or handle hazardous HEATING UNTT(TO 100,000eTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Healthand Safety Code+-Ssedion25537(a)t HEATING UNIT(OVER 10d,000 BTU) - TOTAL:
❑ Yes IJ No '
Wliltheappliant or futurebuilduRoccupantuseequipment oadev.. VENTILATION FAN(SINGLE RFSTD) �1$.-SUQNCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air 6�p
Quality Management District? - - BOILER-COMP(3HP OR 100,000 BTU) '
4Yn F❑.No y Qp
have read the hazaNDa9 materials requirements under Chapter 6.95 of BOILER-COMP(OVE4100,000 BTU) M41 �JJ�
the California l lealth&Safety Code,Sections 75505,25533 and 7:534.1 - 1r/�A d�7
understand that if the building does net comently have a tenant,that R is my NEW RESIDENTIAL MECH. SO.FT
reap ibit y tonotltytheoccopantoflherequiremeniswhi h musubsrrai, Af�ss { t
P/oi to ansofaCe f to ofOccv
Of
4N,cwdirto
cz
/ 04ncr r uthoriud agc ate ISSUED BY:
TOTAL:
OFFICE COPY