22824 APPLICANTT0 FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protea Identification - PERMIT NO. -
Building Address:Lj- per+ �,[ a� A
mere anAPPLICA LION qUBMIrrA
y I /c'��15 CITY OF CUPERTINO-BUILDING DIVISION r
Contractor's Name: LIc.No APPLICATION]PERMIT l
S £ti IIs a BUR.DING-ELECTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL.
Architect/En neer. Oyu o /
"2 // O 6 BUILDING PERMIT.INFO' "
Q1Y', , ECBC'f'RICTERIvITC ` FEE
Address: PERMITISSUANCE ❑ ElElLICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provislona of Chapter 9(.me- APPLIANCESREADENTIAL ]OB DESCRIPTION
ingwith SedIon7000)of Dlvison3 ofthe Buslnessand PrefessionsCode,and my �R
license lain full fe d effect. n PANELS
Lire Class Llc.R L
Date CJ ^el—G/ Contactor -�A;elfOL UPT0200AhTS '
CHITECTS DECLARATION AMPS
' aOZ ]understand myplars ahaB be used spublicrecoOVERi(
rda. OVER 1000 AMPS 5Q.FI.FLOOR AREA At $/SQ.FL.
SIGNSELECTRICAL `�'. �'+?, L E D ' ,Y
k 2 Licensed Profesiowl _
fn¢' 'OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC p T E R
�.., IherebyafRrm that am exempt foam the Contractor's Lirense Law for,the
0z following reason.(Section 7MIS,Business and Preeasioes Code:Any city or TEMP.MRCFROR POLE INST.
r�,� . county which requires a permit to construe[,after,Improve,demolish,or repair /�1,7-14?
�y/j,/ ,
qYY aeystmcturepriormitsissomenalsorequirestheappluesuforsuchpernotto ]OWER DEVICES. DATE ✓` 'Z
L5 C file a signed statement that W he licensed pursuant to the provisiom of the
[WjOu, Contractor§License Law(Chapter 9(commencingwkh Section700()of Dwi- SWIMMING POOL ELECTRIC
30 sio,I ofthe Bukeessanci P ,I,Code)orthat hats exam therefromand VALUATION
the basis forthe alleged exemption. Any violation of Section 7031.5 by any OUTLETS—SWITCHES-FIXTURES
o appBrantfora permit subjects the applicant to a civil penalty ofnnmorethan
five hundred dollars($500). NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�I,as owner of the property,or my employees with wages as their sole
orepensation,will do the work and the structure is not intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law
$$ does not apply to an owner of property who builds or improves theneon,and OCG GROUP RES.UNRS
who doessuch work himself or through his own employees,provided that such
improvements are not Intended oroffered for sale.If,howevep thebuildmg or TOTAL:
Improvement esoldwithin one year ofcompletWq the owner-bullderwlli have .
tltr�urden of proving that he did not build or improve for purpose ofs le.). MY: ' ,` :';p[,[JM$ING�PERMIT FLODDZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
_ The Contartor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such projects with a ;'.EEE$UMMARY?'
m,,IlIlt..[[actorec(s)licensed pursuant W the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under SB&P C for this reason
Owner - Date nu ITS I DE FEES
DRAINS. R,FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RFLER'f a
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-Ire,ora RECEIPT R
certificate ofWorken'Com emation Insurance ora certlBedm thereof(See.
P PY
cS
AEA.SYSTEM-1 INC.40UTLE75 PARK FGE Y
3800,Lab C.y `�' �� ��� / RECEE'Tp
Polity N l
ask,
GAS A)EA.SYSTEM-OVER 4(E
BUILDING DIVISION FEES
Certified copy is hereby filed
the city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER- STORM-STORM F.A.200FT. Date Recei t#
(This section need net W completed lithe permit Is forone hundred dollars
(odorless.) WATER HEATER W/VENT/ELECTRENERGYFEE Y N
I certifythat In the performance of thework forwhich this permit is issued, s
I shall not employ any person In any manner so as to be..subject to the WATER SYSTEM/TREATING
Workern'Compensation Laws of California.Date PAID
z,Z Applicant NEW RESIDENTIAL PLMB. �.FT. Date Recei t#
Z O NOTICE TO APPLICANT:H,aRer making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
LO Code,you moat forthwith comply with such provisions orthis permit shall be n, it !ems BUILDING
FEE
j deemed revoked.
CL C CONSTRUCTION LENDING AGENCY V SEISMIC FEE.I herebyaffirmthet there ie a construction lending agency for the perform- _ TOTAL: ELECTRIC FEE
M Z anceoftheworkforwhichthi Nrmitialsaued(Sm.3097,Civ.C.)
V PLUMBING FEE
O Leader.Name
H LendersAddrcea ql`Y.: ""MECHANICAL.PERMIT` -`:'tFEE:
OW 1 certifythatl have read thisappbcationand statethattheabove Information MECHANICAL FEE
G Is coreact.l agreeto complywllh all city and county ordinances and state laws PERMTTL5SUANCE FEES PAID:
>- CL to building construction,and hereby authorize representatives edible
H N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z Date Recei t#
s
_ (W agree to save,indemnity and keep the City of Cupertino P
agai liabilities,Jtdgments,mets and expenses es whlhl by In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
age said City In ro encs of this permit
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si atvreo Ap cant/Cont ren or ^Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCLOSURE
Will the appBant orfuture building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material is defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Tealth and Safety Code Session 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No '
Will the applicant or turebuildingoompant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air P A RQ
.
Quality Management District? BOILER-COMP 100,0(D BTU) CAS
n❑Ves 1L���No
`FFaveread the haaareeus materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BN) OCT
the California Health&Safety Code,Sections 34
25505,25533 and 255 .1 OJnr
understand that if the bu tiding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. 5Q.FT.
rmpor#ility to notify the occupant of t1be requirements which most be met
Prior Isuance o(a CertiR tc of anry.
60 4 9tTH!�✓�L /Aoar��^f
Ener or2orthoriaed agent - Data BY
' -'TOTAL: ISSUED
OFFICE COPY