20517 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PFRMITNO.
Building Address: t"�0 r r
5I�
0211 S h ,rig'
GL 4 e_ G
vera ame: one:
006 6", L v t �Q CITY OF CUPERTINO-BUILDING DIVISION -
cono-a o aNamr uoNo: APPLICATION / PERMIT — 7— q0
On `a r h O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Archited/Ifiglneer, Llc.No:
- QiY ELECTRIC PERMIT FEES BUILDING PERMIT INFO
A{dress:Z 0 S0 144L C PERMIT ISSUANCE ,ZN uV J��j.� Ky
LICENSED CONTRACTOR'S DECLARATION N '/---„ �g X
Iherebyafflrm that lam licensed uoderprwlsionsof Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DPSCRIFIION
�1 din Sect1on7000)o(Dlvlslon3ofthe Buslnasand Ppro/(eWoneCode,and my
se In In fail(yre and dfect 3 3 O O • PANELS
Licene�Clam I7 Llc M O
Date6 ` Contactor yw(� /
ARCHITECT'S DEC ATIO OVERT201110DAMPS
�7 I understand my piaos shall be used as publlc rvxx da OVER 1000 AMPS SQ.FT.FLOOR AREA §/SQ.Fr:
CO
(s Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SpFLIALCIRCI➢T/MLSC
2 p„�7a I herebyaffiron that l am exempt fromthe Contractor's Llcena Lawforthe
OR—
Qq!y following aason.(Section 7BILS,Business and Professions Code:Antl or
conntywhichrequmapev ttocovetmst,alteplmprove,de=lsh,orrepair TEh1P.METERORPOLEINST.
'� anystrucure pnorto its isuancgasorequhas theappburtfor,such permit to
r0G 6 file a signed statement that he is Rcenied pursuant to the provisions of the POWER DEVICES .
Qw Contractors Lice.I w(Chapter9(commencing with Section 7000)of Divi- SHIMMING POOL ELECTRIC
sion 3 of the Busbass and PracesiauCode)orthat he s exempitherefromand VAQ
the bass for the alleged exemption. Any ,violation of Section 7alls by mOUTLETSSWITC any VALUATION^, XIIIALL TI
O<A appu.at fora permllsubjectsthe applicant to a civil penalty of no ore than 6
$ ccccc five hundred dollars(§500). NEVJ pp.N17A •L 7R '(� RI• TYPE CONSTRICTION
WWW �n
F-1 1,as owner of the property,or my employees with wages as their sale
compensation,will do the work and the structure snot Intended or offered for
prule(Sec.70"Business and Profmlors Code:The Contractors Douce,Law
$ does not apply to an owner of property who Wilds or improves thereon and
"CO w4doessuchworkhimselforthr ghhlsownempleyee,provldedthatwch OCC.GROUP ' RFS.UNITS
improvements as not Intended oroffered for sale.If,however,the Wilding or TAL:
I,Pprovement ssoldwlthln oneyearofcomplMloNtheowner-bullderwill have
t "Mrden of proving that he did not build or improve fur purpo-0fkal ). QTY, PLUMB PER FEE FLOOD ZONE APN
u L as owner of the property,am exclustvely contracting with Ilansed P T ISSUINqy
contractors to construct the project(Sec.7Dbq Business and Professimu Code: Z Q f)
The Contractor's License[aw does norapply to an owner of property who RAIN WA
Wilds or improves re
theon,and who contracts for such projects with a V
ro,,00..t{{scions)Ilcenaed pursuant to the Contractor'.License Law, BACK GCT.D C , FEE SUMMARY -
1_11 am exempt under Sec. R&P C for the rcuon
DRAINS. RODE. SANITARY Y N_ .r
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FDCrURES.I TRAP S IUUL TAX Y N
hereby affirm that 1 have a certificate of consent 10 self-inure,ora RFGER'f M
artlflatoofWorkm'ComPe tlonImurancemamnifiedcopythereof(Sec, GAS -i INC. PARK PIT Y N—
P
Lab C.) 63bo6v
Policya - BUILRECEIDING DIVISION
GAS EA.SYSTFM-0V R (EA)
�� ^Y � —�L7 BUILDING DIVISION F[BS
certified cops(tied
the city GREASE/INDUSIRL INTERCEr PLANCHECK FEE
�CertlBed ropy s(Ikd with the city inspection division.
CERTIFICATE OF CTEMPT[ON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OF1'. Date, Recei t#
(This action need not he completed If the permit Into,..hundred dollen
(6100).H.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I unify that In the performance of the work(orwhich this perms Is luted, —
I shall not employ any person In any manner u as to became subject 10 the WATER SYSTEM/TREATING workers'Compenaationlawsof Califomla. Date PAID
O Z Applicant NEW READ AL PLMB. SQ.F. Date RCCeI t#
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Worker?Comperuatlon provisions of the Labor TOTAL:
y Code,you must forthwith comply with such proWion,or this permit shall be BUIL FEE
W ] deemed invoked.
(LG CONSTRUCTION LENDING AGENCY SEISMIC FEE
O
I hereby a(flrm that there is a construction lending agency for the perform- ELECTRIC FEE
Z TF of the work for which this permit s ssued(See 3D97,Civ.C.) TOTAL:
Oder'.Name PLUMBING FEE
U. F s Lender'.Add a QTY. MECHANICAL PERMIT FEE MECHANICAL FT
O W I artilythxt I have read thsappliatiorand atatethat theabove sformatlon
1 sarreRlagreetocomplywlthallcityand countyordlnancesand statelaws PERMIT ISSUANCE �.I7� FEES PAID:
} N relating to building amtucidon,and hereby authoetu representatives of the
I— U) city to enter upon the above-mentioned property for inspection purposes, ALTERORADDTOMECH. Date Rt#
_ (We)agree.to save,Indemnify an d keep harmieu eCCI the City of Cupertino P
against liabilities,pdgmers,costs and expenseswhich may In anyway acerae AIR HANDLING UNIT fro 10,000 CFM) SUBTOTAL:
qrf said City In on sequ of the granting of tMs permit.
6--7—'7z— AIRHANDWNGIIM'1'(OVQtlO,000CiM) CONSTRUCTION TAX
,gnaly tAppliant/Contractor Date IXFIAUS'C HOOD(W/DUCT) S' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future budding occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) - b0 Date RCCeI t#
motenid as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: k
M Yes No
Will the applianMarc building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) �"D ISO DATE
which emit hacardous air antammans as deflned by the Bay Area Air
lity Management District? BOILER-COMP OHP OR 100,0(0 BTU) 11{� p q 1990
Y. (❑7 No ll
' shave maditchav}7m material,requhomens under Chapter 6.95 of BOILER-COMP(OVER IOD,000 BTU)
the California Health&SafetyCode,Sections 25505,25533 and 7553d.I
understand that if the building does not currently have ate xnt,that itis my NE'WRESIDENTIALMF.CH. SQ.FT. ^., p��p,y
responsibility to notify the occupant of the requirements which must be met ,t(y � cupertitm
prior to issuance of a Certificate of Oavpa ncy. 'a`•
Owueronwhorired agent Data O .0 ISSUEDOV4,
TOTAL: /�
OFFICE COPY