20302APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification '.
Bullding Address:
PE MITNO.
0/00 TDPAe VE UNIT/O f}/a /
2030
vera am . (tvane:
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
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Contractors Name: Ga. a:
ig
BUILDINGELECTMCALPLUMBINGMECygMCAL
CATEGORY CONTROL#
AniatertAngle
rer. Llc No:
QiY ' ELECTRIC PERMIT Sr I fib .
•, ' BUILDING PERMIT INFO
L,.
Address
E
�fi �X �aX
li e I�
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l am licensed under provisions of Chapter 9(marmenc
ing withliomse1 l.fullfamafdeffean3ofthc Busineesand Pro(esslonsCode,end
Incense lslnfun force endetfect.
IDENTTAL
gD ON
7� v,e
J (J )(�/
g201.1"AMPS
License Class Llc.#
Date Contractor
ARCHITECTS DECLARATION Iusdentand myphrushallbeused as publicrerorda
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCRRCUIT/MLSC
OWNER -BUILDER DECLARATION
• Iherefti
byarm that lam exempt from the Contractor's Lima.Law far the
TEMP METER ORPOLE INST.
following manor. (Section 7031.5, Business and Professions Code: Any city or
h requires a pedttomrotruct, alter, Improve, dm
countywhkm eollrh,orrepalr
/p -
anystmc mpr rmlb Wuamc alsortqulmthevppBrantforsurhpert tto
ills a signed statement that he Is licensed pursuant to the provislont of the
Contractor's Gceme Law (Chapter 9 (commencing with Section 7000) of Dial.
slon3ofthe Budn send Profewtom Code)orthathebewmptthem[mmand
POWER DEVICES
•,I
GQI^
SWIMMING POOL ELECTRIC
VALUATION
OUILETSSWITCHESEXIURES
the basis for the alleged exemption. Any Violation of Section 70315 by any
applicant fora permit subjects theapplkant toe civil penalty duct more than
Q�
��
five hundred dollars( .
An
❑ I, as owner of the property, or my employees with wages as their sale
NEW RESIDENTIAL ELECTR SQFr.
a
STORIES TYPE CONSTRUCTION
mropessetion,wHidothe work andthestructure is not Intended or offered for
411. (Br's. 7094, gYBtnc.. and Pmfesslom Code: The Contranort License law
1
does not apply to as owner of property who builds or Improves therecn,and
who doessuch work himself or through his own employees, provided that such
V
OCC.GROUP
RES. UNITS
Improvements are not Intended oroffered Instate. If, however, thebuilding or
TOTAL:
Improvement brild withnomyearofcompl&Wb tMe ner-b Merwlll have
thl ttirden of proving that he did not build or Improve for purpose of nkQW..).
U I, as owner of the property, am exclusively contracting with accused
contractors to cowman the project (Sec. 7044, Business and Profession Code:
"�
Q, PLIIMBING;PERMIT+y,." y;, t FEE
FLOOD IDNE
APN
PERMIT ISSUANCE
Tice Cantsct.e. Lt.. law does not apply to an owner of property who
builds or ionp. thereon, and who contracts for such with a
P Plo)Kft
the Conervctors Lfceve Law.
.B(Ectmexe exempt
LJ I am exempt under Sec B & P C for this mason
AL�'DRAIN&VENT -WATER ISM
''TTS)'-FEE(SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT#
Owner ' Date
WORKMAN COMPENSATION DECLARATION
❑I hereby a((Irm that I have • certlBcate of consent to self -loan, or
ceml(Icate o(Worken'Comperaationimurance ora certifled copy thereof (Sec.
3800,Iab C.)
Paltry #
FD(.TURFS PER TRAP
SCHOOL TAX Y_ N_
RECEIPT #
GAS FA. SYSPFM-I INC4 OUILRTS
PARK FEE Y N
RECET'CX
GAS EA. SYSrFM-OVER 4 MA)
Com any
BUILDING DIVISION FEES
fiedcopybhereby(umished.
erttned ropy b inwlih the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GRFASETAAP
CERTIFICATE OF IXEMPTION FROM WORKERS'
PAID
SEVER-SANITARY.SPORM EA 20OFf
COMPENSATION INSURANCE
(Thlssection need not be completed If the permit bfor one hundred dollars
Date Recei t#
WATER HEATER W/VENT/Fr FC.FR
ENERGY FEE Y N —
($1W)or nese.)
I mrtlfythat In the perfomunaaf the work (.,which this pemdt is Issued,
WATER SYSTEM/TREATING
I shag not employ any pesos In any manner at as to become subject to the
Worken'Campenutbn Lawso(GH(omIs. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after melding this Certificate of Exemption, you
NEW RESIDENTIAL PLMB. SQ.FT.
Date Recei tin
TOTAL:
should become subject to the Workers' Comperuation provisions of the Labor
B I
Code, you most forthwith comply with such provlslom or this permit shall be
deemed revoked.
- CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Ar 31'
I hereby a/Omnthat there Is a construction lendlagagency for the perform
ance of the work for which thio permit is blued (Sec 3097, Civ. C.)
Leder. N.'"rPLUMBING
Lender's Addms -
I.AifythatlhavemadthisappHcatlonand& Wthattheabove In(omatlon
bcommt. I agree to comply with all city and county ordinancesand elms laws
TOTAL
ELECTRIC FEE
QTY. MECAANICAtzP,ERMIT,�;:;:.,, ' ;'FEB',
FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building contraction, and hereby authorire representation of this
city to enter upon the above-mentioned property for Wpection purposes.
(We) agree to save, Indemnify an d keep hanrdess the City of Cupertino
against liabilities, jadgments,m#s and expenses which may In any way accrue
ALTE.RORADDTOMECH.
-
Date Receip"I
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
.T
agawt/.aiac�x+n %��� g%ra gaf this pe tc�
�e
AIR HANDLING UNIT (OVER to oleo CFM)
CONSTRUCTION TAX
.�" "_' "Q
" '
Signature of ApplfantARDO ctor bite
IXfIAl15T HOOD M'/DIKT)
CONSTRUCTION TAX PAID:
HA2ar RDOUSMAT LSDISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recei tin
WHlthe applied by the Lure building occvpan ode, hapten leharardom
as defined by led Cupertino Municipal Code, Chapter 9.t2, and the
Health and Safety Code Section 75532(a)7
Health
❑Yes �] No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
s0
VENTILATION FAN (SINGLE RI3ID)
IS$C'171N(17[ -A'j'E
Will the applicantors devim
occoprsed
cantaruildisg
by theequipmentArea
hahemitnagement is rottamWcab as de0ned by the Bay Area AI
a Illy Management District?
Lj Yon n No
F 4"&a-'u�►•
q
BOILER-tbMPpM'OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)�
have read the hammous materials requlremens under Chapter6.95 of
the California Health & Safety Code, Sections 255115, 25533 and 25534. I
understand that if the building does eta mrrently have a tenant, that It Ismy
responsibility to notify the occupant of the requirements which= at be met
j
' Clty Of (�IIjIP,i lliin
NEWRMDENDALMECF[ SQ.FT,
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Data
- TOTAL:ISSUEDBY:
OFFICE COPY