21945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PELUdT NO.
Building Address: I
e21945
cus
'WI wnere a
CITY OF CUPERTINO-BUILDING DIVISION A
jA. md/Fn7gJmer.
aresNo: APPLICATION I PERMITBUrLDINGQ.ECTIUCALPLUMBINGMECHAMCAL CATEGORY CONTROLLk,No: QTY ELECTRIC PERMIT , FEE BUILDING PERMIT INFO
PERMTIS5UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby efflm�that l am licensed under provisions of Chapter 9(mmmenc- APPLIANCESRFSIDENTIAL
Ing with Section 70100)of Division 3 ofthe goodness and Pro(essrtmCodgard my OgDESCRIPTION
Moi� rer(�a
lice°n�yssea Is In fall fu—u-Dome—ane effect. -1 PANELS
Lice ' " I LIHIe. S `tel 1, !"I
Datil__i ContractorLIP TO 2D)AM
ARCHITECT'S DECLARATION M
OVER
APS
Q�u p70 lundemtand my pians shall be used upubllc records. OVER 1000 AMPS SQ.FT.FLOOR AREA §/SQ.FT.
E�E Licensed Professional SIGNSELECTRICAL
EG'7� OWNER-BUILDER DECLARATION BPCCIALCBtCU1T/MLSC
Z 1h..byafRrmthat l am exempt from the Contrador's Limose Law for the
following reason.(Sc ticn 7071,5,Business and Professions Code:Any city or
O I:. TEMP.METER OR 1'OL
�4 caanly cram riortoaspemdttoalsore uirestheaplicamf rsuch,ormpair
mitto
anyatructurc pdorm its iseuence,aisorcqutreathe appllant(w such permit to 9�6POWERD CFS
c. B4 a signed statement that he is licensed pursuant to the provisions of the
3wContractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi-El In SWM
OJ slonI of the Business and Professions Code)mthat he is exempt therefrom and VALUATION
•] the basis for the alleged exemption. Any violation of Section 7071.5 by any
applicant for a pernJt eubjectethe applicant toacivil penaltyo(nat more than
five hundred dollars($500).
�n ❑L as owner of the property,or my employees with wages as their sole ECTR SQ'Fr' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
n, sale(Sec.7094 Buslna.and Professions Code:The Co rtmot re.License law _
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RESUNn-s5
who doe.suchwork him rif orlhrough hisovenemployees,provided that such
Improvements are not intended oroffemd forsale.If,however,thebulldinger TOTAL:
Improvement issold within oneyearofcomplatom the owner-bu0derwill have
the*rden of proving that he did notbulldorlmpmve rorpurposso(uleJ. QTy, a PLUMBING PERMIT FEE IIIDODZANE MN
LJ L as owner of the property,am exclusively contracting with lirensed PD2MIT ISSUANCE
contractors to construct the pmject(Sec.7044,Business and Professions Code:
The ContnRor's Liomse law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves the , and who contracts for such p-ojecta with a
Tyl&or(.)licensed pursuant ro the Contratlo/s License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY.
am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE FEES-
Owner Date RECEIPT is
WORK MAN COMPENSATION DECLARATION
❑ wFDCI'URES PER TR" SCHOOL TAX Y N
I hereby affirm that I have a arti(kate of consent to self-In
re,or RWMPT N
38ULlab
certificaterken'Compevatlonlnsurana araartifled copythereof(Sec. GAS EA SYSDBN-T INCA OUTLETS PARK FEE Y N
Pol3$00, bc.)C.)
RECEIPT N
Company GAS EA,SYSTM-OVER 4(EA) BUILDING DIV
ISION FEES
Ljj�ertifled copy 6 heed with the cit. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCI-IECK FEE
ertNed copy is Ned with the city Inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA 700Ff. Date Recei t#
00)
(0 mleulon need not M completed If the perMt isfor one hundred dollars
(81orless.) WATER I BEATER W/VENT/ELECTR ENERGY FEE Y N
IartRythat brise performance o(lhework forwN
ch lisle permit ie Issued, N—
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PWB. SQFf. Da1C Recei t#
Z NOTICETO APPLICANT.(,after making this Certificate of Emmptlon,you
Hshould bemmenubject to the Workeri Compensation provision.of the Labor TOTAL:
CCN Code,you at forthwith mmply with such provesoru orthls permat shallW
j doomed revoked.CONSTRUCTION
BUILDINGFEE
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is amuwction lending agency for the perform- TOTAL: ELECTRICFEE
(�7 O arm of the work for which this permit is Bound(Sec.3097,Civ.C.) PLUMBING FEE
Lender's Noma -
ly F Lend era Add now QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I comity that l have read t his application and orate thatthe above information
CL is mrreci.Iagree to comply with all city and county ordinances and Rate laws PERMrT ISSUANCE FEES PAID:
>. W relating to building mnstrunloa,and herebysuthorlu representatives of this
F— Z uty to enter upon the above-mentioned property for inspection purpose.. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an a kap harmless the City of Cupertino Date Receipt#
against liabilities,prig is,costsand ex ^aesw Ichmayleanywayaccrom AIRHANDLINGUMTGO10,000CFM) SUBTOTAL:
against said Cl 1 o e oft otin- this mtit.
\ AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTIONTAX
fwwl
Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
]ALS DISCLOSURE
the applicant or fulur Tiding occupant store or handle hazardous BEATING UNIT(TO 100,000 BTU) Date Recei t#
materW l as defined by the Cu rtlno Munidpa l Code,Chapter 9.17,and the ate,
Health and Safety Code Section 75937 fail HEATING UNIT(OVER 100,000 BTI!) [RAM,y , AL: l
RYes Na
illthea ppgont or luturc Wildingcempantusaequipmenlordevims VENTILATION FAN(SINGLE RESID) 7GUANCE DATE
conk ct haurdeus all mntarNmnbas defined by the Bay Area Air Nj17t-,N J
Quality Management District? BO
ptm OR 100,0(10 BTN
4Y- [2No
have rcadthehaza oua materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,000 BTU)
the CalifetoIs Health&Safety Code,Sen ions 75505,75533 and 75534.1 ✓:£I+CeCt,��+yy
understand that tithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be mot
prior to issuance of a Certificate of Ocm pa noy,
O.vner or authonud agent Date ISSUED BY. �+VV'V/Vl./K.Jw"��
TOTAL:
OFFICE COPY