20903 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idamitlntlnn - PERMIT NO.
Building Address: -
T561 TI Toe L� . -P IND , ►• �50�� 20903
orae.
CITY OF CUPERTINO-BUILDING DIVISION 9 W19 Li.No: APPLICATION /PERMIT
Architect/Engiver. Llr.Na: D BUILDINGS,ECTRICALPLUMBINC-MECIIAM !1 CAL CATEGDCO
- QTY ELECTRIC PERMIT FEE BUIrDING PERMIT INFO
Address
Z� ISj� ❑
i LICENSED CONTRACTOR'S DECLARATION PERMlTIS5UANCE I"CPt
I hereby affirm that l sen licensed under provision s of Chapter9(commme APPLIANCESRESDENTIAL JOB DESCRIPDON
Ingwith Se Clm,on7000)ofDlvlaon3o(the Businessand Pro(emian°Code,andm
license is In full to.and affect. PANELS _
Lic.
Date Contractor
Q -ARCHITECT'S DECLARATION 701-1000 AMPS
0ZO Iundenhnd my phvsluB be used mpubBcremNs OVER 1000 SQ.FT.FLOOR AREA f/SQ.FT.
Lken.d Pro(emlovl SIGNS EL
<
Q OWNER-BUILDER DECLARATIONI hereby TAT, CUI
owingraffirmtectlam31.5,Bxempt fromthed Prefaar's License Law for the My
or
O rn Q fo8owing myon.(Section 7011.5,Business and Profealons Code:My city or
Kul" county which requires a permit W consteucLalter,Improve,demolish,or repair IFA4P.M LE
any structure prior b its issuance,also requires the applicant fo .t ch permit to POWFRD
file a signed statement that he h licensed pursuant to the provisions of the
3s' Contractor's License Law(Chapter 9(commencing with Section 7000).(Divi-�O glyIMhg CTRI slon3 o(the Businemand Pro(eeu-noCcelOmthat hels exempttherefeemand - VALUATION
EE{{ the bash for the alleged exemption. Any violation of Semon 70115 re any OUTLE TC ��ggyy �v_J
O liden1(or red doles aubjechthe eppllcanstoa civil pevky of na mmrethan SC.0 / 6 (/
five hund..na, TIM W). NEW RESDFNIIAL � / s
I,as owner of the Property,or my employees with wages as their wk SOFT. 5rOS6 TWE CONSTRUCTION
compensation,will do the work and the structure Is,na Intended or offered for
O vie(See 70M Business and Professions Code:The Contractors License Law
$ don not apply to an owner of property who builds or Improves thenen,and -
whodoeasuchw.rkhm tforth.ghhlsownemploym,provldedthatmch OCC.CROUP RBUNITS
Improvements are not intended orof(ered forma,.lf,however,thebulldlag w TOTAL:
Improvement hsold withlnoneyearofcompletlogthe owner-buflderw111 have
Hlg,�urden of proving that hedid not build orlmprove for purposeo(saleJ. QTY. PLUMBING PERMIT FEE
u L as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCEhT'�D APN
contractors to construct the project(See 7044,Businessm
and I'mfebeo Code:
The Contractors Limn.law dm not apply to an owner of property who
bullcis or Improves thereon, and who contra for such plujdm with a ALTER-DRAIN A VENT.WATER(EA)
.p((aaor(s)licensed pursuant to the Contractor's License Law, FEE SUMMARY
LJ 1 am exempt under Ser. .B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Dae DRAINS FLOOR ROOF,ARIA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION�. RECEFr 1❑I hereby affirm that I have a certificate of consent to.Ihln.re,or FIXES TURPER TRAP SCHOOL TAX Y N
certificete of Workers'Compensatlonlnsuranceore certlfkd copythereo((Sec. RECEPr N
3800,Lab GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y_ N
Policy 8 RECER'I p
Cam any GAS EA.SVSTITI-0V1iR4(EAI BUILDING DI VISION FEES
[PCertltied copy h herebyth the ad.
GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certlfletl copy h(Ikd with the city Inspeal.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE �(�
(rMssenion needna becamplaed Rthepamon isforovhundred dollars SEWER-SANITARY-STORM PA."11r. Date Recti (#
(5100)orless) ENERGY FEE Y �ap (p
Icee[Ifythat In the pceformancems
o(the work(orwMch this permit blswWATER HEATSd W/VENT/ELFLTR
Issued, N_
"hall not empty any person in any manner.m to become xubjea to the
Workera Compensation Laws of California.Data PAID
WAT°I � /��xTING
O Z Applicant _
Z O NOTICE TO APPLICANT.if,after making this CertRlvle of Exemption,you NEWRESIDENTIALPLMB.__SQFr. Date Rernf t#
N shmld become aubjcat.the Worken'Compensatlon provblov.(the Labor TOTAL: �.
_ Code,you must(oninet comply with such prevbiovorthis perant°hall be
W > deemed revoked. BUILDING FEE
(Z a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there isa co.auction koding agency(or the perform,
Z anreofthe work(orwhlchthh h Issued 6ec.3097,Civ.C.) TOTAL; ELECTRIC FEE
U 2 Lender'.Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerti(ythal l have read thhappllcatlonand state thatsheaboveln(orerutlon
a Iscorme.I ageesto comply with all city and countymetinances and state laws PERMIT ISSUANCE l 4J FEE$PAID:
} N rehtingtobuildingconstructive,and herebyautherlumproadd.tivesofthis
Z cltyloenterupoothe above-mentioned propanyfor Wpealon purposes, l ALTER OR ADD TO MECH. aCv
(We)agree to cove,indemnify an d keep harrouess the City of Cupertino Date Receipt#
against liabilities,Pdgments,codsend expenses which may in anywayacaue AIR HANDLING UNrr(to 10,000 CFM) SUBTOTAL•
against sold City in consequence of the granting of this Famous.
AIR HANDLING UNIT(OVER I O,WO CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or fewer building oavpant store or h Odle harallous HEATING UNIT(TO 1 ILODO BTU)
macrhl as defined by the Cupertino Municipal Code,Chapter9.12 and the _ Date - Reaei t#
Health and Safety Code'action 25537(a)7 IIFATINC UNIT(OVER 100,000 8TU) TOTAL:
❑Yes Na
Will the or tare building—part use equipment or device VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous.h conta
minant.a.deftned by the Bay Arca Air PAPQuality Management District? BOILER-COMP OHP OR 100,000 BTU)
❑ Yes ❑No
O (have rcadtheh.arclou.mterlalsmqulmmenhunder Chapte,6.95.f BOILER-COMP(OVER 100,000 BTU) ���
the Olifomh Health&Safety Code,Section,25505,75533 and 75534. I lU"eeQAYl+1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH, SQ.FT
respoviblllty to orally she occupant of the requirements which must be met
prior to Issuance of a Cord Bcste of Occupancy. Ma
Owner or authodud agent Date ' ,� • ' ISSUEDBY:Y , IY���I�VC=e-.
TC3TA L: x
OFFICE COPY COPY