21900 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PF41MTNO.
B.0ding Add ruse n 1 9 0 0
assn: VIA one: ' / G I YJ
CITY OF CUPERTINO-BUILDING DIVISION
f 'rase,' '�—v� wa.N.: APPLICATION / PERMIT
N BUILDING-ELECTRICALPLUMBINGMECHAMCAL CA'IFLORY CONTROL X
Al.,ft, ,r
gineen Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address �TfjdX I1?a_1wDr PEWTISSUANCE �1 L[f 1:1 ❑ ❑
LICENSED CONTRACE -R'S DECLARATION
IM1erebyafluenl1u 'tentimasedund rprovi arse,of Chepter9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION '
ingwlth Sndon7000)of Divlsloa3.ft a alnos.and Prof.1...Crainandmy
license bin t (ore and effect. PANELS
Chat
dense CLIc.R
Date Contractor —UP TO 2DOA�Tg
ARCHITECTS DECLARATION 201-1000 AMPS
p�u
9
0 O I understand my plana shall be used as Public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FF.
k� Licensed Professional SIGNS ELECTRICAL
6 OWNER-8
OLDER DECLARATION
a SPECIALCIRCOT/MISC
I herebyafRrmthst I.exempt frornthe Contractors Llmnee Law for the
f.11.wing recon.(SMion 7m1S,Business and Pro(emlane Code:My city ar
O TEMP MEI'QT OR POLE INST.
pcwntywhlch nqulmeapermlt tomnstruct,altenlmprove,demollah,.,repair
any structure priorto its lusearce,alao requirestheappllcan forsuch permit to LOWER DEVICES
R file a signed statement that he is limned pursuant to the provisions of the
0 Contractor's License Law(Chapter 9(commencing with Section 7000)of Diel- SWIMMING POOL ELECTRIC
slon3 of the Businamand ProfeulunsCode)orthat he assempt therefromand VALUATION
5 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLEISSWHFS
CHHXTURES
applicant for a permit the applicant to a civil penalty of not roam than �QO a
five hundred delbu(S500). NEW RESIDENTIAL ELEC7R SQ.Ff. STORIES
�n ❑1,as owner of the property,or my employee with wage.a that, Is TYPE CONH7RCONSTRUCTIONCONSTRUCTION
compensation,wBldo the work and thestructure is not Intended or offered for -
q sale(Sec.7064,Business and Professions Code:The Contractor's License Taw
$ docs not apply to an owner ofproperty who builds or Improves thereon,and OCC.GROUP RISS UNITS
Msownemployees,provided that such
improvements are not intended oroffered forage.If,however,thebuilding or TOTAL:
Improvement Issold within one yearufeompletion,the owner-bu0derw111 have
t}BLIlurdenof proving the he dWrwt build.,Improve for purpose ofuk.). Q7y, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
dentracton to mrotfuct the project(Sec.7044,Bu.ineu and Professions Code:
The Contractor's License Law doe not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wild, or Improve.thereon, and who contracts for such pwget. with a
uplTactoK8)Banned pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_J I am exempt under See mas
B A P C for this ers
OwnerDate DRAINS FLOOR BOOP,AREA,COND. SARFARY Y N_
RECEIPT$
WORKMAN COMPENSATION DECLARATION Fp(7vRES.PER TRAP SCHOOL TAX Y N
Of hereby affirm that I have o Insurance
of consent to epythemof ora RECEIPT I
certificate of Worken'Comperoatlonlnsunnm ora certl(kd mpythemof(Secs
300qab CJ GAS EA.SYSTEM-I INCA OUTLETS PARK FFEEY N
Policy It GAS EA.SYSTEM-OVER d(EA) DING DI M
C ffen BUILDING DIVISION FOES
HITT Certified mpy b herebytumec1tyfisluel. CRFASR/WDUSFRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified mpy V filed with the city Inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t
Ohla section need not he completed if the permit Is(or one hundred dollars
($10 unity that
WAFER HEATER W/VENT/EI-EC'TR ENERGY FEE Y N
I enol that In they pargenaneof thewoh an ast become
seermlHa blued, —
I shall not employ any person 1n any manner an u to become subject to the WATER SYSTEM/TRFATING
W.rkcrApplicant
s'Compensation Laws of California.Date PAID
O Z NOTICNEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z O nt APPLICANT: ager making this Certificate of Exemption,you
Hshould become subject to the Workeri C.mperoatlon provisions ofthe Labor TOTAL:
NT
Code,you=at forthueth comply with such powbiom orthis permit shall be BUILDING FEE b-00
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirm that there is.mrWruction landing agency for the perforrry ELECTRIC FEE
Z arm of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertltylhatlhave read this eppkatlonend patethatthe above lnfornutlan
1 bmrtect.l agreete,comply wlthall cityand county ordinances and elate laws PEIMTTISSUANCE FEES PAID: -
} N relating to building mnstrocti.n,and hereby mthorlu representative ofthin
Z city to enter upon the above-m.ntionell property for inspection purposes. ALTERORADDTOMECH. Dale Recei t#
(We)agme to save,Indemnify an d keep harmless the City of Cupertino P
agahnt liabilities,fidgmenb,costs and expenses which may in anywayaence AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
against mid City in datesequenceofflis granite ofthi Permit.
I AIR HANDLING UNIT OVER 10,MCFM) CONSTRUCTIONTAX
Signature btA cant/ContractorDate DUAUST]iOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBent orfnam building occupant store or handle hazardous HEATING UNIT OO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Sifely Cede Sectl.n 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Q
yea r!No
Ilithea pplimntarfuWm Wlldingmmpantuuequipmentordevices VENHLATIONYAN(SINGLE RESID) ISSUA �E
which coat hazardous air centamimnts as deRned by the Bay Area Air
Quality Management D�Icti BOILER-COMPOHPOR100,00011TO MqR 1219 1
4 Yrs No
have read the haze ous nutedala requircmenh under Chapter G95 of BOILER-COMP(OVER 100,000 B'fU)
the Califorala I Iealth h Safety Code,Sections 25505,25533 and 25536.I
understand that if the building doe not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT. city
q
responsibility to notify the occupant of the require
requirements which=at be met !EMI '"w
priortolexuares ofa Certificateofeccupancy.
Owner.raulM1orbed agent Data ISSUGDBY:
TOTAL:
OFFICE COPY ' •.