21356 _/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project ldemificatim )A
PERT NO.
Ouilding Addm
� qutaZ m21356
nets ams: one: A
S I att'{7 h 5pmj CITY OF CUPERTINO-BUILDING DIVISION / O^ Zq�
e "ora Nam: Lie.No: APPLICATION I PERMIT L 1 !
Arch to ^ yk' BUILDING-ELECnUCAI.PLUMBINC-MECH LAICAL CATEGORY COJO7R0J.ly
QTY ELECTRICPERMIT FEE BUILDINGPERMIITIINNFFO
Address: PERMIT ISSUANCE 'Ls(,�' (<X � I�j
ereby LICENSED Ikemed under pnwhnmo;.fChxpho9
DECLARATION j/_'J /e�J "
IhthSedilRm that lamMon3aftheerprovbldPm Chapier9(co..d APPLIANCFSRESIDEMfAl JOB DESCRIPTION
Ingwllh Sect1on7000)ol DiWsl.n3ofthe Buslnmand Professtone Code,and my �UG
license I.In fu and effect. /$ $. JJ PANELS //�Y re�.�(0''��
CIqqss LIc NwQrIN' R- 't�-=ptiov,
ate Contractor
ARCHITECIPSDECLARATION 201-IODOANPS
gyppp±±DCO I understand my plane shall he used a t public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT,
E U t, Licensed Profmlowl SIGNS ELECTRICAL'
teag OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC I (�'
7F, a Ihersbyaflrmthat l am exempt from the Contractor's License Law for the
following reason.(Section 70313,Business and Profeaslons Code:Any city or
Ft'u9 cwuntywhichrequlraapert ttommtmct,aiter,impmve,demolbh,orrepair T�P.METEROR POLE INST.
anystmctum prior to its hxxoucq alwrequum.theappliant forsuch permit to
la`K file a signed statement that he Is 11¢n.ed pursuant to the prevoomot of the POWER DEVICES
Contractor's Licewe law(Chapter 9(commencing with Section 7000)of Divl-
'30 s1on3 ofthe Business and Professions Code)orthat he is exempt themfromand SWIMMING POOL ELECT VALUATION
y1 the basis for the alleged exemption. Any violation of Section 70715 by any
applicant fora permit sub' the applicant to a civil nal of not mom than lO OUTLET'SSWITCHESFl ES
PP ed of le"+ PP penalty L G OCJ OO�L
five Nunn owner
hepr. NEW RESIDENTIAL EL JQFT. STORIES TYPE CONSTRUCTION
In /,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure b not Intended or offered for
Ci sale(Sre.701y Business and Pro(miore Code:The Contactors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROI/P RES.UNITS-
word.
CC.• ..chworkhlmseliwthroughhisownempIWees,provldedthatwch
improvemcnl.arenot Intended oro(feredfo..ale.lf,however,lhebuildingor O (�
Improvement rs sold within omyearofcomplmioq the owner-buUderwUI have
Uke Wrider,of proving that he did not build or improve for purpose of sale.). QTY, Bi ERM IAODZONF.FEE FAPN
0 I,as owner of the property,am exclusively contracting with licensed PERMIT I ANCE I^ 00
contact..to construct the project(Sec.701 Business and Professions Code: P Y
The Contractors Llmnec Law does not apply to an owner of property who ��g-DRAIN
Wild. or Improves thereon, and who contacts for such pwject.with a - �) V L�
�quj[seines)Banw pursuamtothe Contractor's LicenseLaw. BACK PLOW r r.DEVI a FEE SUMMARY
I_I I am exempt under Sec. B k P C for this reason
DRAINS AREA,COND. SANITARY Y N�
Owner Date RR A RECEI'Ta
WORKMAN COMP a ceAT10N DECLARATION FU(•f[IREL PER lam SCIIOOLTAX Y N
❑[hereby affirm that I have a certificate of consent to cel(-Inavre,ora l RECEIPT M
rodiffate of Workers Compensation lrsuran¢ora occulted copythereof(Sec. I GAS EA.SYSrEM-1 INC. r PARK PPF. Y N
3800,fab C.)
Policy M RGCFlII'T X
Com an GASEA.SYSTEMA R<(EA BUILDING DIVISION FEES
�cc copy is filed with the city sherebyththe ciity
erti0ed copy Inspection division.
CREASE/INDU WASTE INTERC- PLANCHECK FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREASE TRAP "-RGYFEEY
COMPENSATION INSURANCE SEINER-SANITAR STORMEA 2islin(Thiawctlonneed nO becompleted Uthe permitb(Drone huntlmd dolls. WATER HEATFRW VENT/ELECTR I¢notthat oyIn an peva s in an theork fo asto b camhis esubjecrmit is Lto theed,I shall not employ any Lam In any manner w as to become subject to theWATER SYSTEM/TREATING IZA Workers'Compensallan Law.of GII(ornla,Date O Z ApplicantZ ONOTICETO APPLICANT:I,aftel makingthlsCertifiateofExemption,you NEWRESIDENTIAL PLMB. SQF7sh.uldbecomesubject to the Workers'Compomatlon provisiaru'of the Labor Code,you must forthwith comply with such provisions orthis permit shall bedeemed revoked. FEE
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyefgrmlhat there is a construction iendingagenry,forthe perfomt s(,'17 ELECTRIC FEE aC19
Z ance of the work for which this permit is Issued(Sm.3097,Civ.C.) TOTAL:
V 0' Lander'.Name PLUMBING FEEf.f a�
IL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ¢rtifylhatl have read th0appilationa drtatethat the aboveinfoneadon
a iscomect.I dgree to complywithall city and county ordinances and state laws PERMIT ISSUANCE IZOD FEES PAID:
�. W relating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date RCCCI
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Pf#
again.(llabll dgment1.=.and expenses which may In anywayamon, AIRHANDLINCUNIT(T010,000CFM) - SUBTOTAL:
against gal Ity conaeyuence.fill grand gof this pemnut.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigtutureofpplant/Contracts Date IXHAUSIHOOD(W/DICT) CONSTRUCTION TAX PA ID:
HAZARDOUSMATERIALSDISCLO RE
Will the epp0ant or(afore building occupant store. handle hazardous HEATING UMT(TO t00,0000TU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ^�
f lc❑lt Yansd Sf(tyCade,Lx Se�ctloon 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 3'3t
WMltheappllant.nature bullding occupant use equipment or devices I VEN'1TLATION FAN(SINGLE RESID) �'s'S� ISSUANCE DATE
which emit hamoJects air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP OHP OR 100,IX0 Bila
Yea[
n❑No
have read the hazallous materials requirements under Chapter 6.95 of BOILER-COMPER100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 2:530. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI'
responsibility to notify the occupant of the requirements which at be metS
prior to Issuance of a Certificate of Occepanry. 2 �Q. �� V l.t�Qd VX
Owner or authorized agent Data
TOTAL: O. ISSIIEg "�-t I
OFFICE COPY