20078 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
lbulci ng Addrem:
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[4F_Il,LUT—PAcycAQD CITY OF CUPERTINO-BUILDING DIVISION
cant"°° Ge.Nce APPLICATION 1 PERMIT
BUILDINGELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL N `
!
M/ gS _ PHEAJ 7' NoQTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres: oWDA - )ZO CJW10D
PpRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l see licensed under provisions of Chapterl)(cernmeme, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
70M)of DiAsion3ofthe Businessand Professions[ode,and my
license is in full f��and effen. PANES
License Claes Llc.N
Date Contractor
ARCHITECPS DECLARATION 701-11100 AMTS
rc0 O �,�•1/ryy��^ertalyl rr 1 Is be swim ub1iR c remrde. OVER 1000 AMPS �.FT.FLOOR AREA SQ.FT.
04 LlceNstd7' Vis Iovl �l �1 LI SIGNS ELECTRICAL
U 6 Lu OWNER-BUILDER DECLARATION SPECIAL CIRC MISC
7 p,�5 I hereby affirm that I amexempt fromthe Contractors License law far the
following reason.(SMion 70115,Business and Professions Code:Any city or
O TEMP.M OR INST.
l=E countywhich requlmapennittoconstmct,alter,improve,demolbh,orrepilr
g acystructure pdortoibisuance,also requlrestheapplicant for suchnnid"o POWER
•ES file a signed statement that he Is licensed pursuant to the provisions of the
O i Contmdor's LicemeUw(Chapter9(mmmendngwith Section7000)of IN SWIM LEL C VALUATION
SE,OS sion3 o(the Business and Professions Code)orthat he is exempt therefern
the basis for the alleged exemption. Any vlolatkm of Section 70715 by any ETSSWI FI
appBant for a permit subjects the applicant to a civil penalty of nalmore than
w 0a five hundred dollen($500). ESI ELEC .Ff. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
7Q mmpcnsation,will dothe work and lhestructure h nm Intended or offered for
O
-in(See.70K Business and Prfemiom Code:The Contractorh Lirense Law
$ does not apply to an ownerofproperty who builds arimprovee thereon and V IOCC GROUP RES.UNITS
who docmuch work himself orthrangh his own employees,provided that such
Improvements arc not Intended or offered formic.If,however,the building or TOTAL:
improvementheuldwithtn oneycarofcompletlon,theowner-bullderwill have
thti�urdenofproving that hedidnotbuudorlmpmvemrpurpoeeofmle.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner tr the property, Se exclusively Business
and Pro with Iicenvd PERMIT ISSUANCE
contractorsto constructthe (Sec.70pl to an
Professions Code:
The Contractor's Improves
Umme Law does net apply tct an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contacts for such p(okM with a
Curls)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &P C for this reason 3
�r DRAINS FLOOR RODE,AREA,GOND. SANITARY Y N
• Owner ECLDat — RECEIPT'N
WORKMAN COMPENSATION DECLARATION FIXTURE&PER.I.RAP SCIIOOLTAX Y N
❑I hereby affirm that I have o certificate of concent to pytheure,ora RECEIPT N
3800,Lab C.Worken'Compensationlnsumnce ora certlfkd copythernf(5ec. GAS FA.SYSTEM-1INCA OUTLETS PARK FEE Y N
Policy
Erb C.)
Polity M REcECom 'M GAS EA.SYSl77dAVER d(EA)
any BUILDINGOING OfDI VISION FEES
Certified copy is hereby famished. PLA
GRGSE/INDUSTRL WASTE INTIRCEPIDR NCHECK FEE
Certified copy is filed with the city Inspection division, a!
CERTIFICATE OF EXEMPTION FROM WORKER S' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE
(Thiseectn SEWER-SANITARYioneed not hecompleted lfthepermit lsforanehundred dollars STORM PA.700FT. Date Ret' t#
($I00)oify th Y_ N_
I coca loat In the performanceof the work(arwhlch this permit le heed, WATER HEATER W/VENT/ELECTR ENERGYFEE
I shall s' employ any Laws in any manner eo u to become subject to the WATER SYSTEM/TREATING C✓�,Z,Gv
Worlicant Compensation Laws of California.Date PAID—/—L— I
O Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date ReceI til
Z NOTICE TO APPLICANT.If,seer making this Certificate of Exemption,you
should become sublect to the Worknn'Compensation provisions of the Labor TOTAL:
CC (A Cade,you must forthwith comply with such provisions orthh permit shall be
W > acemea revakeS.a. OO
Q. G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there h ro
a coroation lending agency for the perform, ELECTRIC FEE
se
M Z cenof the work for which thh h TOTAL:
permit Issued(Sec.3097,Civ.C.) L: PLUMBING FEE
V O Lender's Name
LL Iendne.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certifylhat l have read this appllcrRn
oaod statethat theaboveinformation
a lecomed.I dgmeto comply with all city and counlyordinances and state laws PERMIT ISSUANCE FEES PAID:
>.
W relating to building construction,and hereby authorise representatives ollhis
I' Z city to enter upon the above-mentioned property for impaction purposes. ALTER OR ADD TO MECH. Date RCCeI tN
z Me)agree to save,Indemnify an d keep harmless the City of Cupertino
agalrst BahWtks,jiLdgments,cromand expenses which mayln anywayaccrue AIRHANDLINC UNIT(TO 10,000 CFM) SUBTOTAL,
agYai�mnisa�id1 Cityinconsequence o(the anti this permit.
pm( _ 57T605 t2-q0 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI(Iruture of Appll.ant/Contradorr Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aavpantetmem-handle hanrdoua HEATING UMTEFO 100,W0 BTU)
materialas defined by the Cupertino Municipal Coda,Chapter9.IZ and the Date ReceI til
flealthand SafetyCodeSect1un7553Ha)? HEATING UNIT(OVER 100,000 BTU) - - TOTAL:
❑ Yea M No
Will the applicant or future bullding occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ��tSGi)p NCF DATE
which emit havardom air contaminants as dAned by the Bay Arca At, L��VS'"P�1��9M�
Quality Management District? BOILER-COMP OTR'OR 100,000 BTU)
n Yea nl�No
Thave read the huaraous materlals requirements under Chapter 6.95 of BOILER-COMP(OVE2100,000 BTU) ap �p
the California Health&Safety Cade,Sections 75505,25533 and 75539.1 MIR
fs 100 4 I'vr:;u
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH.' SQ.FT.
responsibility to notify the omnpant of the requirements which swat be met �t� qq rraNm�
I lmuaneeofa CertlRcate of Ocmpanry. Clay of U 'nil nertinn
IAJL P'Irz�k_dS 'f-2_70 `.
Owner or aulhoriced agent Data
TOTAL: ISSUEDBY. CL
OFFICE COPY