20205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buileln Ym'ect Identification PERMIT NO.
Building Address:' '9 7 Sh�.7ic_,� D r• Cup _ 20205
neva ,9p p A A A
l ��1 a%'3 - gell 25Z-SSPE CITY OFCUPERTINO-BUILDING DIVISION �q
Contractor's Name: Lie.N. APPLICATION I PERMIT Z
Architect/Engineer. Lk.N. BU DING-ELECTRICAI4PLUMBING-MECHAMCAL CATEGORY CONTROL N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmss: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby am7X)that ofDfv Bcensedunder lnessanmof Chaper ssions9de,and nc- APPLIANCES-RESIDENTIAL J08 DESCRIPTION
Ingwlt 1Sect1oll forces and
of1he8u.inenand ProlesslonaCmde,and my
license is In full force and effect PANELS � 11 R�
Llceac Clan LicY
Date Contractor `M It
ARCHITECTS DECLARATION MI.1000AMPS
OZ I understand my plans shallbe used as publlcrecords OVERIOOOAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
CO r,
re d e Licensed Professional SIGNS ELECTRI L
L as
�< OWNER-BUILDER DECLARATION $ LCIR T/
jC
p., 7 Ihereby affirm that I am exempt fmm the Contractor's License law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
Fcountywhich mquiresa pemtittommtmn,alter,improve,demidah,orcepalr TIN ' O INST.
$ any structure prior to Its issuance,also raqulres the applicant for such permit to
FSO U file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License law(Chapter 9(commencing with Section 7000)of Divl-
H�O� Bion 3 ofthe Business and PmfessionaCede)orthat he is exemptthemfro and 5 NG ELC C lI VALUATION
the basis for the alleged exemption. Any violation of Sedlon 7031.5 ny
' <r. ppli.ctfurs permit subjectstheapplicanttoacivil penalty anotmoret n O E WE HIS-FIXTURES .S C6, 00
F f mod ownermd am(5500). W RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
..�n I,as owner of the property,or rq employee with wage as their e
t ons sat tom will do the workand the strutters Is not Intended or offe or
5 O nk(Sec.70K Business and Profeniom Code:The Comratlols License w
� $ dons not apply loan owner of property who Wilds crimp rovcathereamand OCC.GROUP RES.—UNITS
whodo mchworkhl lforffiwghhisownemplgees,provided thatsuch
improvements are not intended croffered for sale.If,however,thebuildin TOTAL;
Improvement lssoldwithinaneyearo(completion,the owner-WilderwiIt a
tt�uMen of proving that he did not Wed or Improve for Purpose of sale.). QTY. P B G ERMIT FEE FTppp ZONE ppN
Lj L as owner of the pmperty,am exclusively mntraRlng with Iimnsed P U CE
contmctms to construct the project(Sec 7044,Business and Professions Cade:
The Contmetorb License Taw does not apply to an owner of property who AL INA WATER(EA)
Wilds or Improves thereon,and who contracts for such plujects with a
cQ➢tt dor(s)licensed pursuant to the Contractor's License Law. BACK FIA OT[CT. CE FEE SUMMARY
LJ I am exempt under Sec B A P C for this reason
DRAINS R RODE,AREA,CONED. SANITARY Y N
Owner - Data
RECEB'T p
WORK MAN COMPENSATION DECLARATION FIX.TU PER TRAI' SCI;OOL_TAX Y N
❑I hereby affirm that 1 have a lr urate of consent d spythsure,ora RECEIPT'N
3800,Late olWorkeri Compensationlnsuranceoracertified copythereo((Sec. GAS E.A.SY$T�-I INC.4 OUTLET
Poli fab CJ PARK FEE Y N
Policy Y RECEIPT M
Cam ny GAS EA.SYSCIM-0OVER B UIL DING DI VI SION FEES
�CeniRed copy 6 hexiwreby th the city
d. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CenlBed ropy ls flied with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MOVE Date Recei t#
Rhlsseatlon need not W completed BtW perrtdt ls for one hundred dollam
(Sl N)nrlenJ WATER HEATER W/VFNr/ELECTR ENERGY FEE Y N
I isnot that In the person
In an the workmancer so as to
permit to tjd —
i shall not employ any person f any manner so ns m became subject to the WATER SYSTEM/TREAUNG
Wmrkers'Compensatlon Iowa of California. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:IT,after making this Certificate of Exemption,you NE'WRESIDI:NTTALPLMB. SQ.Fr. Dale Race) [#
should become subject to the Workers'Compensation provisions of the Labor H TOTAL:N Cadmi
Cade,you mu at forthwith comply with such provisions or this pert shall be / L�<
W > deemed revoked. UIL TNG FEE
a C CONSTRUCTION LENDING AGENCY SEISMIC FE
I herebyaffirmthat there ixacommiction lending agency forthe performn E
ELECTRIC E
Z ance oflhe work forwhichthis permit is Issued(Sec.3097,Civ.C.) TOTAL:
(� O Lander.Name PLUMBING FEE
LL 1- Lender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL PLUMBING
FE FEE
O W I mcifythat l have read thisappticationand state that theabove information
(L Is coined.[agree to comply with all city and county ordlnanmand state laws PERMIT ISSUANCE FEES PAID.
} W relating to building construction,and hereby authorize representatives ofthb
F Z city to enter upon the above-mentioned pmperty for Inspection purposes. ALTFRORADDTOMECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale Receipt#
against liabilities,lodgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO a10,0DO CFM) SUBTOTAL:
.Be t said City in mnsaquence of the granting of this permit.
)"L y LLf/,.t )e' l?_PQ � 2s_9V AIR HANDLING UNIT(OVER I0,000CI:M) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HFA TING UNIT(TO IDgODO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: �.�
Yen r]No
Iilthe applicant or Niumbulldingocaupant use equipment ordevices VENTILATION FAN(SINGLE RESID) I$SAII ILAP�A•LE
which eMtharaedmusair
trict' ants as defined by the Bay Area Air tV+ V{bY2
Qu lily Maagcrrent DlsMct? BOILER-COMP PER'OR I W,IXD BTU) APR
y
4Yes I INn APR 4 a �ytlV
Its read the hav s materials requlmments u ndcr Cha pter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have atenant that it is my NEW RESIDENIIALMECH. g1.FL CIOf CllOertI11G
riaponslblllty to notify the occupant of the mqulremema which must be met v V
prior to cauance of a Certificate of Occupancy.
Owner or authmnzed agent Uate ISSUEDBY4
TOTAL:
OFFICE COPY
r