21681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 01 e I wx 1 r PEIMITNO.
Building Address: /'�q j8(�
2.o �� G I
t-eviuit. ante. one:
G CITY OF CUPERTINO-BUILDING DIVISION
c etradoesName: Lte.No: APPLICATION / PERMIT _ l
11 BUfLDING-ELECTRICALPLUMBING-MECI IANICAL CATEGORY CONTROL N
Ardlite-dfiEn er. Llc No: '
BUILDING PERMIT INFO,
;Q?Y. ,i EL$CTRFG;�'ERMIT -FHS
Address PERMITISSUANCEP4 ❑ F ❑ [:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commmc- APPLIANCES-RESIDENTIAL JOB DESCRU'TEON
ingwllh Section 7IX00)of Divisim3ofthe Busime and Pmfessl=sCode,and my
license la in full force and died. PANES
License Class G" Lk.p
Date - Contractor I 201 TO 200
AMPS '
HI S DECLARATION
❑ret. I is my Ube d as public records. OVER1000AMPS SQ.FT.FLOOR AREA -$/SQ.FT.
(Ev
00
6� License rofeask, -- SIGNS ELECTRICAL
GGGG 6 w O R-BUILDER DECLARATION
In SPECIALCRCU[T/MISC
Zp, IherebyaNrmthat am exempt from the Conlractor'a License Law for the
o following reason.(Section 7031.5,Business and Professions Code:Any city or
OZi.. TEMP.MEIPlt OR POLE INST.
p� county which requires permit bcoruttact,alter,improve,demollsh,orrepalr, _
any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
r file a signed statement that he is licensed pursuant to the provisions of the
y{� Contractor's License Law Cha r9 mrmrcncin with Section 7000 of Divi-
SWIMMING POOL ELECTRIC
07 on3ofthe Businesaand Profembru Code)orthxe
atthelsempttherefromand
aiVALUATION
6 the baeb for the alleged exemption. Any violation of Section 7031.5 by anyl gtc OUTLETSSSWITCHES-FIXr RtES2�l
O applicant for a permit subjects the applicant to a civil penalty of net more than
fivyoundred dollars($500). NEWRFSIDENTIALELECTR SQ.FC. STORIES TYPECONSTRUCTION
�n I;as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure la not Intended or offered for
qsale!list.7094,Business and Prefessloru Code:The ContraRor's License Law
5$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does suchwork himself or through his own employees,provided that such
improvements are not Intended oroffered formic.If,however,thebuilding m TOTAL:
improvementasoldwithlnoneyearofcomplelorytheownerbullderwillhave
tFeliurden of proving that he did not bund or improve for purpose orsals.). Qi Y.'a, ....:PLU�VIBING.PERMIT "'y,'FSE' FLOOD ZDNE nrN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontradmen to construct the project(Sea 7014.Business and Professlom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
builds or improves thereon, and who contracts for such ptojccts with a FEE SUMMARY.
coMador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sea B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y ' N
Owner Date RECEIPT p
WORKMAN I haw a COMPENSATION DECLARATION E(TURE-PER TRAP SC[;OOL TA% Y_ N_'
❑i hereby or� that I have o lmurate of consent m pythemo ora RECEIPT p
certiflLab of Workers'Comperuation lraunnce ora certified ropytM1ereof(Sea GAS EA.SYSTEM-1 INC.40UTLETS PARK FEE Y N
350D,Lab C.)
Policy p RECE'T p
Com - GAS EA.SYSTCM-OVER4(EA) BUILDING DIVISION FEES -
rtNedcopylshercbytumlehed. '
CeriSled roN
copy Is ed with the city Inspection divwlon. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200ET. Date Recef t#
(This section need not be completed lithe permit is forone hundred dollars
($100)orle.a WATER HEATER w/veNT/ELECTa ENERGYFEE Y N-
I certify that in the performance of the work for which this permit is issued, —
I shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workere'Compensatlon Laws of California.Date PAID s
O Z Applicant FLEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate ofExemption,you
should become subject to the Workera'Comperuatlon provisions ofthe Labor TOTAL:
N Code,you at forthwith comply with such provisions orthls permit shall be
WC deemed revoked. - BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirrethat there Is a ronstructlon lending agency for the perform- TOTAL ELECTRIC FEE
O ance ofthe work for which this permit is Issued(Sec.3097,Civ.C.)
V Leader.Name - .. PLUMBING FEE
LL F Lendcr.Addreas - QTY: MECHANrCALc'PERMIT '`:FEEL? MECHANICAL FEE
OW 1certify thatl have read thisapplicationand statethattheabove information
IL is mrrect.Iagree to comply with all cityand munty ordinances and slaw la PERMIT ISSUANCE FEES PAID:
>- relating to building ronstmition,and hereby authorize representatives ofthis
N
(— Z city to enterupen the above-mentioned property for Impedton purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# _
IS i stliabllit"'judgments,rest.iied expenses which may In anywayaccrue AIR HANDLING UNIT LTO 10,000 CFM) SUBTOTAL:
ad tsaid City In a en granting o(thb permit. •
AIR HANDLING UNTr(OVER lQuixi CPM) CONSTRUCTION TAX
na eof App ra / "trader Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will eapplleant fulurebuildingcxeupxnt store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Sedlon 25532(a)? HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yes �i No
Will theepplirant orfuture building ocmpantuse equipment ordevices VENTILATION FAN(SINGLE REED) ISS TE
which emit hazardous air contaminants as defined by the Bay Area Air ,
lily Management District? BORER-COMP OHPOR 100,0M BTU) �� y�Q�
I Yes' �No ,� 1 31
have readthehaza ousmaterialsrequlremenw under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI)
the Califernla Ileallh&Safety Code,Sections 25505,25533 and 25534. I "
understand that lithe the ing doesoccupant oft a rreuirainets which thatb met NEW RESIDENTIAL MECH: SQ.FT. ry�y wi MuloM{IM
priors issuancty e
of a Certificate
oftoftherequlrementewhich must be met - �Rl 1SAR� .La'S•��
prior to issuance ofa Cetlifitiw o(Ompanry.
dD
Owner or authorized agent Date ISSUED 6Y:'\\y�VO•.l`"a••'e-t-
TOTAL:
OFFICE COPY