21445 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proect Identification I PERMIT NO.
Building Address:
VIAe,4N1'Na 21445
Z�l 9
wnera"arm: one: A
CITY OF CUPERTINO-BUILDING DIVISION l_ ^^O
N�S7 Lie.Nn: APPLICATION 1 PERMIT C
Archimet gineer5. - L o: BU)LDINGELECTRICALPLUMBING-MECIIANICAL CATEGORY
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISUANCE ❑ ❑
LICENSED CONTRunder rDECLA RATION
[hereby
ection7 that amdon3 ofthe erprovland Pm Chapter 9(commenc APPLIANCFSRESIDENTIAL JOB DFSC ON
ing with Dl effect flhn Bualnssand Pro(eselonsCode,andm L�
Ilcense is In fol dd(ect. ` Q PANELS
LlcenseC s LIcN \\
Date Contncto UP TO 2DO AMPS
ARCXI7E SDC ATION 201-I WOAMI'S .
SCO IuedenWnd my plans shaft be used spubec recatda. � 0 OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.IT.
o1(Wv/ Lkeowd Professional SIGNSELECTRICAL
06 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
z s-e)i-1 I hereby affirm that I am exempt from the Contractor's License Taw for the
^ following imsen.(Section 7031.5,Business and Professions Code:An tt or
TEs- counlywhich requires a permit to construct,alter,bnprovs,densulk,h,orrepair P.M PO ST
anyslruclure pdorto Its Issuance,also requlrestheappBcent forsuch perndtto
�a file a signed statement that he is llcenwd pursuant to the provisions of the POWER DEV[
O Contractor's License Law(Chapter 9(commendngwithSedlon7000)ofDlvt-
�O sion3ofthe Businesand ProfexbnsCode)arthathebexempttherefmmand NG LELE C VALUATION
the bask,for the alleged exemption. Any violation of Section 7031S by any
Oapplicant fora permit subjects the applicant to a civil penalty of net more than Off' IJ� L�
$ five hundred dollere(5500). NEW E SQ.IT. STOWS TYPE CONSTRUCTION
�n I,ea owner o(the property,or my employes with wages as their sole
compensation,will do the work and the stm=m k,not Intended or offered for
D sle(Sec.7004,Business and Professions Code:The Contractor's License Law
s$ does not apply to an owner of property who Wilds or Improve.t hereon,and I . VOCC.CROUP REL UNITS
who docs such work himself orthrough his own employees,provided that such
improvements are not intended oroffered far sale.If,however,the W ilding or TOTAL:
Improvement Is sold within onsycarofcompleimy the owner-W llder will have
tl)p„Lvrden ofpmving that hedid net WRd orimpreve for purpose olcaled. OTY. PLUMBING PERMIT FEC Fhppp 7pNE ApN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
comrade.to co-firoct the project(See 7004,Business.od Profesians Code:
The Contractor's License Iew does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilda or improves thereon,and who contracts for such pSlejec s with a FEE SUMMARY
w
o%JP.0or(e)If...dpursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE e�
LJ I am exempt under See. B k P C for this mown BACK CD OUTS I QF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data R13CEIPT N
WORKMAN COMPENSATION DECLARATION .URI�.TRATP SCHOOL TAX Y N
hereby affirm that I have•certificate of consent d spytheure,ore REC=N
380DmdlL bC) orken'Compensatlonlnsunnce ore certified copy thereof(See. GAS FA.SYSTEM-1 INCA OUTLETS. PARKF-EE Y N
350QLb C. oO ^��1 RECEB'FN
Policyp 1 L/ I_/ ���d���
Com anv � CAS EA,$YSTEMAVERd(FA)
S If AI BUILDING DIVISION FEES
JC Eed copy Is hereby fumhihed. GREASEANDUSIRL WASTE INTERCEPTOR PIANCHECK FEE
enli ied copy Is filed with the city inspection division.
CERTIFICATE OF ExmPTION FROM WORKERS' GRE-ASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANTrARY-STORM RA 20017E Date R 1 t#
Rhm genion need not W completed I!the permit k,(Drone hundred dollars
(flfI mmly th WATER HEATER W/VENT/ELECTR ENERGY FE� Y
Icenet that In the persouiaofthewek for which this permit ccawed, �-
1 shag not employ any person In any manner n as to become abject to the WATER SYSTEM/TREATING
Workers'Compensationompenution Laws of California.Date PAID
C1 Z Applicant NEW RESIDENTIAL PLMB. SQFL a O CCeI ttl
Z O NOTICE TO A17LICANT:If,after making this Certificate of Exemption,you
Hshould Wcomewbjed to the Warken'(Compensation provisions of the Labor O L:
W Code,you=at fort hwith comply with such provIslom or this permit shall
LU > deemed revoked. _BUILDING FBE Z
d C CONSTRUCTION LENDING AGENCY SEISMIC FEE 1,S4
Iherebyaffl hat there Is a constmdion lending agency for the perform TOTAL:
ELECTRIC IEE
Z anceofth.worklorwhichthis permit is Issued(Sec.3097,Civ.C.)
V Q Lender's Name PLUMBINGPEE
ICD
u. Lend.e.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW, I ootlfythatl have readthis applicullonand statethat lheabove ln(armatlon
C Is correct.I agree to comply with all cityand county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} fA relating to building construction,and hereby authorize representatives a(this
L. Z city to enter upon the abovcmentioned property for Inspection purposes. ALTER OR'ADDTOMECH. Date RCCeI fed
Z (We)agree/o save,Ind tons fy an d keep harmless the City of Cupertino
against liabilities,}.tdgments,torte and expenses which may in anywayacerus AIR HANDLING UNIT(T010,000 CFM) SUBTOTA
a teal Ity l consequence of the grant) S of this permit.
AIR HANDLING UNIT(OVER I0,000 CIM) CONSTRUCTION TAX
SI• lure of AppEmn ommct ate IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA
HA BOGUS MATERIALS DISCLOSURE
Willtheapplla rat or future building occupant Store or handle hazardous HEATINGUNITR0300,0DOBTU) Date
RCCeI 1
mater lasdefinedbythe Cupertino Mudcipal Code,Chapter9.12,andthe - _
Healthand Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTA �5
Q Y. �I+� No
Will the applicant or fu tum building occupant uwequlpnentordevlm VEMMLATION FAN(SINGLE RESID) Irjr�P��A-I-E
which eMl hazardous air contambu is as defined by the Bay Are a Alr
Quality Managcoant DOlstritt7 BOILER-COMP QFB'DR 100,000 BTU)
Y.
Y
I d No DEChave read thchazar ouamaterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) E4199
w
the California Health k Safety Code,Sort co25505,25533 and 25530.I
understand that if the building does not currently have a tenant,that it k,my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the mqulmmenta which moat be met •aX�ss
0 Copan
priorto issuance of a Certlfiate of0ecupancy. FbdfUll'siN"
Owner or aulhodzad agent Data IS B .
TOTAL:
OFFICE COPY