20254 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Building Add toss:
f0 I 20254
ICEV/ GT.
wnera am.: one. p
L CITY OF CUPERTINO-BUILDING DIVISION
. CoeractoraN.mc: Lk.N.: APPLICATION /PERMIT S-
2:7(0-c-,48 BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Arele tect/Engfneer. Lk.No:
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: l�JI 21,At1-�VkaS./�� PERMTTISSUANCE ❑ ❑ I1C I�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commone- APPUANCESRISIDENTIAL JOB OFSCRUIrnON
Ingwlth5 ton70o0)of DiWkon3ofthe BuAnessand Pm(eaal...Code,and my
license is In full force snd eflea. PANELS
License Cla C• k.N
Date��Contnctor
ARCHITECT'S DECLARATION Nl-IEEE AMI'$ )
"!. I understand my plans shall be used as public records. OVER 1000 AMPS I // SQ.IT.FLOOR AREA $/SQ.FT.
O
E d 3 Licensed professional SIGNS ELECTRICAL \\\\ Is k+
�nzia OWNER-BUILDER DECLARATION SPEC LCI2CUIT/MISC
t., 7G7 Thereby afOrm that l am exempt from the Contractor's License Law for the y
O9F following mason.(Section 70'f1.5,Business and profession,Code:Any city orTom{ ETERORI'OLEINST.
qcounty which requires a permit to construct,alter,improve,demolish,or repair
G �s anysvucturepriortoltsbwance,aMmqulmatheappliantforsuchpemtto POW46VICES,
fS O CGil U ilk a signed statement that he is licensed pursuant to the provisions of thev� /I1
�3 G Contachr'.License Law(Chapter 9(mmrrcncingwith SMion700)).(Owl- SWIM POOL ECTRC V Cill, VALUATION
O slon 3 ofthe Business and ProfessionsCode)orthat he b exempt thercfromand G 6
pV���.' the basis for the alleged exemption. Any violation of Section 7011.5 by any OU7LH.IS uFiFSII%7TJRBS ` I
tj ty�5 spplant for a Fors.m
Forms subjects theapplicant to a civil penalty of nore than - a �
five hundred dollars(5500). NEW RFS[ ENTIALEIEC FI'. l
01,as owner of she property,or my employees with wages as their sole STORKS TYI'C CONS'II2UCTION
o�� ,O compensasion,will dothe work.and shestmeture b not Intended or offered for
sale(Sec.7N4,Buslnes.a io
and Professns Code The Contractors License law 1
,, $ does not apply to an owner of property who builds or improvn thereon,and \) t
p$^ whodoessuch work hrts
keRorshrough hisoweemployees,provided that such OCC.CROIBP RES.UNITS
Imprevemenbare not intended oroffered tarsale.If,howevegthe building or / TOTAL:
Improvement b sold within oneyearofcompletion,the owner-W Ilder will have
t"relen of proving that he did not build or Improve for purpose of sale.). QTy. PLURBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively contracting we.Ikensed PERMIT ISSUANCE
contractors to construct the project(Sec.70M Business and Professions Code: � Q
The Contractor's License Law does not apply so an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wild.or Improves thereon, and who contracts for such pPjects with e
oq=aet.e.)homsed pusses..to the Geometers License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec. B &P C for this masonOUTSIDE FFrS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEBT N
WORKMAN COMPENSATIONDECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a artlRote of consent so self-Insure,.r a fD �_t)� RECEIPT N
es00`icono Workers Compensation Insurance m a certifkd copythe se(See. GAS EA.SYSTEM-i INCA OUTLETS PARK FEB Y_ N_
RECEI T N
;,,policy Y GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Company
`J certified copy is hereby famished. CREASE/INDUSTRL WASTE INTERCEPTOR , 00 PLANCHECKFEE
/{`]((-CertUed copy b(Iled'Mth the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT Date Recei I#
(TMssectlon need not W completed If the permit b for one hundred dollars n
(5100)or less.) WATER IdEATFR W/VEM'/ELECTR . OV ENERGY FEE Y_ N_
I artllythas N the performance of she wmk(or which this.permit is loved,
T shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of Califorela.Date PAID
C! Z Applicant hIEW RESIDENTIAL PLMB. SQFT. Date Recel ted
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions the Labor TOTAL:
wCC Code,you most foe hwith comply with such provisions or this permit shall W -BUILDING
eecmed ma.ked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
'
Il O Iherebysffirmshat there b a construction leadingagcnry forthe perform- TOTAL: Q ELECTRIC FEE
Z ance ofthe work forwhichthla permit b isseed(Sec.3097,Cie.C.) �� PLUMBING FEE OD
(� O lender'.Name
LL H Tcnder'a nddmss QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
OU I artilythat l havemad this application and statethattheabove Information �� FEES PAID:
W Is correct l agree to comply with all city and county ordinances and stale lam PERMIT ISSUANCE
O' relating to building construction,and hereby authorise representatives ofthia
cit t entero nthe above-mentioned property!mInspection set. ALTER OR ADD TO MECH. Date Receipt#
Z Y° W P partyitPure°
(We)agree to save,Indemnify an d keep swhics she City of Cupertinoceme AIR HANDLING UNIT(TO 10,000 CFM) v I O SUBTOTAL'
U against liabilities,jrdgmenb,cost.and expect Ce which may In any wayaccrue
againstsaid City lnconse .fine gnI gqf Wspermit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 1Q000CFM)
Sigwturc of pl nt/Contractor ^Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATEIII SD CLOSURE
Will the applicant or future building store or handle havrdous I HEATING UNIT(TO 100,000 BTU) 700 Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealsh and Safety Code Section 25532(a)7 HEATING UNIT(OVER WQOW BTU) TOTAL:
❑Yes Sr N.
Will the applicant or suture building occupant use equipment or devices /y VENTILATION FAN(SINGLE RESID) , O d ISSUANRC&DATEis ��
which emit ha7ardnus air contaminants as defined by the Bay Area Air
• Quality Management Deateicti I BOILER-COMP OFT'OR Iffy"BTU) (
�,x
Yes No en
have read the haaa oro materials requiremts under Chapter 6.95 of BOILMFRW
ER-COP(OVIW,OBTN JAAY U J t)-
the California health&SafetyCode,Sections 25505,75533 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RCSI DEN-HAL MECH.-SQ-1-7.
responsibility to notify the occupy nt of the rcquircments which most be met City B/ Cllnln'tlno
prior to bout nce of a Certificate of Occupancy.
1. t
Owner or authorised agent Date ISSUIEDBY: K
TOTAL:
OFFICE COPY