20916 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ii Project ldentlflcetan PERMIT NO.
BuI1dt BAdd ' S�ir-n .. 20916
wnersName: one
0390 l7Ell! 7f ITYOFCUPERTINO-BUILDING DIVISION
ontractor'e Name: Lie.No: APPLICATION /PERMIT C//
Archlteci/Engineer. Lie.No: BUILDING-E.ECTRICALPLUMBINC-MFGHANICAL CA'IFLARY CONTROL N
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMHISSUANCE - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcessed under provisions of Chapterg(corrartanc, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section7000M Divis n3ofthe Buslnessand ProfesslonsCode,and my
license Is Infull form effect..Nc PANELS
License Chss L
Dale Contractor
ARCHITECTS DECLARATION 201-IOOOAMN
otOz I understand my plant shall be used as public mexuda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
qO
(/ Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION S7+ECIpLCBiCU1T/hiLSC
Iherebyaflrenthelamexempt fromthe Canlractors License Lawfmthe
following reason.(Section 7031.5,Business and Professions Code:An oft or
O k.� Y TEMP.METER OR POLE INST.
PE �
county which rcqulresa peaNtrocoutugalter,Improve,demolish,orrepair
�G any structure prior to its Instance,also requires the applicant for such permit to (OWER DEVICES
K file a signed statement that he Is licensed pursuant to the peovbioo,of the
Oki Contractor's License Law(Chapter 9(mmmencingwith Section 7000)ofDivi- SWIs(MING POOL ELECTRIC
/
30
4on3 of the Busineu and Professlom Code b mthat he exempt therefromand U VALUATION
the basis f the alleged exemption, Any violation of Section 70115 by any OUTLETSSWIICIiESIl%Il1RFS
0 applies ora permit subjectstheapplicant to a civil penalty of not more t Kan
R flu ar-
dred!dollen($.500). NEW RESIDENTIAL ELECTIR SQFI,— i TYPECONSIRUCTION
�n I,as owner of the property,or my employees with wages as their sole
t compensatlonwllldothe work,andthe structure le not intended or offered for
s q sale(Sec.70141,Busburea and Pmfemioro Code:The Centimeters License law
does not apply to an owner of property who builds or improves thereon,and /C.GRDUP RES.UNITS
GG who does such work himself orthrwgh his own employees,provided that such
Improvements are not intended oroffered forsals.If,however,thebulldingor TOTAL:
Improvement bsold wfthin omyearofcomplsttary the owner-budderwill have
tir-*rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1 v D
contractors to coutrud the project(Sec 7U4.Business and Professions Code: l
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or Improves th n, and who contracts for such piolecta with a
caRarWld sant to the n rorsL ..Law. FEE SUMMARY
LII am Y er &P C rot this reason BACK FLOW PROTECT.DEVICE OUTSI OF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT N
WORKMAN COMP�SATION DECLARATION SCHOOLTAX Y N_
❑I hereby affirm that I have a ceMficate of consent to sell-Inure,or FIXTUIff_^'I'ER TRAP • RECEIPT N
3800,Lab
C.) S EA.ao(Worken'Compematlanlmurance ora ttrtlf4d ropythereof(Sec. GASYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,
Policy N GAS EA.SYSTEM OVER d(FA) RECEI"N
Com any BUI LDING DI VI SION PEES
ffCertlfied copy b hereby furnished. CREASE/TNDUSTRL WASTE INTERCEPTOR PLANCFiECK PEE
c.mned copy is filed with the city mapemmn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
PAID
COMPENSATIONINSURANGE SEIyER-SANITARY-STORM FA 2DBF 1• Date Remi t#
(Thos section need notmbebe comomplciN lithe permit foram hundred dollars
(51 I othifY that
WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
Icer[Ify[hat In the perfurnance of the work for which this permit is Issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTLM/TREATIN'G PAID
Workers'Compensation Lawn of California. Date
0 Z Applicant NEW RESIDENTIAL PLMB.__SQ.FT. Date Remi tit
Z 0 NOTICE TO APPLICANT:ILafterruking this Certifkaleaf Exemption,you
Fshould becomesubject to the Workers'Compensation provblona of the Labor TOTAL:
tl7 Code,you moat forthwith comply with such provisions orthb permit shall be O G B�
LL > deemed revoked.
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there b a mrutuctlm lending agency for the perform,C.I m TOTAL: ! ELECTRIC FEE
Z ante of the work for which this permit is issued(Sec.3097,C1v.
U 0 lender's Name PLUMBING FEE
LL I- Lenders Add reas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ittdaveread Ilthapplicatbnand
i(ythatlhsatethattheabove lnfarmatlon
1 bromet.I agree to comply with all city and rountyordlnann:stand sate laws PERMIT ISSUANCE FEES PAID:
>_ N relating to building mutmctfon,and hereby authorlae mpreencrulvn of this
(— Z city to enter upon the abovarmntioned property for inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,Indemnify d keep harmless the City of Cupedim Datc Receipt#
aIt
almtl es,N nM, a xpen which may In anywayacwe AIR HANDLING UNIT CIO 10,000 CPM) SUBTOTAL;
gal Ity n c tt t gra ofthls permit.
AIR HANDLING IINIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous BEATING UNIT(TO 100,OW BTV)
ruterlal as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date Rmei t#
i iealth and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yes M No
Will the applicant crfutum building omtpant use equipment ordevlces VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air ceobMtanb as defined by the Bay Area Air PAID Quality Management D❑istrin7 BOILER-COMP OHPOR 100,0(D BW PAID
4 Vee N No
have read the Fara oust materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
(J T) �G9�
the Zifernia Health&Safety Code,Sections 75505,25533 and 155X. I t,T v
understand that if the building does not mreently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which moat be met
prior to Lotus.o(a C rificammoccupancy. City Cat• (stlmorti11R
Owner or authorised agent Date �t, a
TOTAL: ISSUED BY: VIVC
0FFICE COPY