20785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
y I Building Pro'ed Identification PERMIT NO.
Bdrome
1B03d17 V15TA KNOLL BLVD, 20785
OwneL VA IL
W.ra a S*rAk C7• '�. - 0.+5-2577 CITYOFCUPERTINO-BUILDINGDIVISION �Qq: Phone: APPLICATION SUBMI I A
Contractor's Name: 1Q Lin No: APPLICATION /PERMIT
U W N e \ B=TNC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL 0
Archiied/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. I'ERMITISSUANCE ❑ ❑ ❑
Lm that ED CONTRACTOR'S DECLARATION
I hereby affirm that .1o.3licensd under ftheBuprovisions andPmfhmsr9(coand my APPLIANCES-RESIDENTIAL )OB DESCRIPTION
It...1 Scalars f.me.f d ofiion3o(the BuMnessand Pmfesslona Code,and my
Lloms Is In Inst force and .# PANELS
License Clan Lina
Date.Contractor UP TO 200AM5V.J`W V llJ
ARCHITECTS DECLARATION 201-1000 AMPS
otZp I understand my plana shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
ti Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M1SC
7F. Iherebyaffirm
that iemexemplfromthe Contractor's License Law for the
following mum.(Section 7031.5,Business and ProluedoCode:Any city or
rF . TIIDSP.MET[R OR POLE INSf.
, muntywhlchrequ4 aper tommtmec niter,lmpmve,dennllah,ormpalr
14 anysimd mprwrto166mance,abomquimstheapplluntforsuchpermitto
9O file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3�I- Contractor.License Law(Chapter 9(comtrcncing with Section 70M)of Divi. SWIMMING POOL ELECTRIC
slon3 ofthellualnenand Profenlom Code)mthat he 6 eumpttheretromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
¢S
applicant fora permit sub'ed.thea applicant to s civil nal elect OUTLEISSW[TCHESPI ES"�
A t Pe I PP penalty O OO
C` Hundred dollar(f.500). NEW RFSIDEMIALE 7R SQ,Ff. SCOWLS TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages an their sole
compensation,wlldothe work and the structure is not Intended or offered for
O sale not
apply to an ainowandf property
lds or improve,
mprovLicnue Gw
$ wh.d tapply l.rkhi .lfmth ertywhobutmplay n,pv ithermR and C.CROUP RES.UNITS
EE whodvements are net mnlf edormfered ownemp,lumv,ex,the d building
r _
Improvement are net Intended arofcd(°reale.If,howeverlhebuldingve TOTAL:
Improvement iswld within oneycarof complMlory the owner-W Iderwlll have
theme rden of proving that he did nm build or improve for purpose ofule.). QTY. PLUMBING PERM FAD ZONE ppN
Lf I,as owner of the property,am exclusively contracting with licensed pp�{CC ISSUANCE
contractors to m.bvd the project(Sec.7044,Business and Professions Code:
The Contmdor's License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER�A)
build. or improves thereon,and who contracts for such p(oject with a
cj5acior(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
Owner Date FEOUTSIDEFEES
E SUMMARY
LJ 1 am exempt under Sen B A P C for this reason
'
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
WORK MNACOMPENSATION DECLARATIORECEITRN FD(TURES PER TRAP SCItOOL TAX Y N
❑I hereby affirm that I have o Insurance
ra c of consent w opytheure,ora RECEIVE 0
3800,certifLab of WorkersCoops.atlanl.unnceoracertifled copy lherco((Sec. GAS EA,SYSTEM-1 INCAOUTLETS PARKFEE Y N
3800,Lab CJ
Policy a GAS EA.SYSTEM-OVER 4(PA) RECEIPT M
Com anY BUILDING DIVISION FEES
Certified copy is hercbyth ilhe city CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy to filed with the city Inspection divielon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date ReCel t#
IT e section need not becomplMed lithe permit isfor ane hundred dollars
(SI OOJ or1cai') I. WATER HFATTR W/VENT/ELECTR ENERGY FEE Y N
Imnete employ
the so as toblhl.pesubjcissued, —
I shall net employ any person In any manner so u to become subject to the WATER SYSTEM/TRGTINC
Workers'Compensation Laws of California.Date pplp
O Z Applicant NEW R151DPNIIAL PLMB._SQFT. Date Re i t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
sbould bemme.ubject to the Wmknn'Compewtlon Preview.of the Labor TOTAL:
W
Code,you most forthwith meoply with ouch pmvisiou orth6 pemu.hall be
`J deem ed revoked. U L
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a mnstmdion lending agency for the perform ELECTRIC FEE
7 z once of the work for which this permit is bwed(Sec.3097,Civ.C.) TOTAL
(� O Lender's Name PLUMBING FEE
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Imrtlfylhat l have read thisapplcalion and Matelhatthe above Information
O W
1 bcomet.I agree to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorise represenlativesoflh6
F Z city to enterupon the abovemenlioved property for Inspection purpose.. ALTFRORADDTOMECH.
(We)agree t e,mdemNfy ice humiess the City of Cupertino Date Receipt#
V .gala I1lIa I grrcnt,co and xsy which tlmy In any we a c AIR HANDLING UNIT([010,000 CFM) SUBTOTAL'
a$al i ronacque fl IT n armlL 27 AIR HANDLING UNIT(OVER I0,0()0CFM) CONSTRUCTION TAX
I
Ig.tureo Applcant/Co d Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD W TERIALS .CLOSURE
Will the applicant or future (dingoccvp tatorc or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei f#
material as defined by the C°Pertlno Municipal Code,Chapter 9.12,and the
Health and Safety Code Sealant 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea No
WII)nit applicant building occupant bythc equipmomt Area devima VENTILATION PAN(SINGLE RESIUI ISSUANCE DATE
whkhemithara rdow Ir comaM.nts as del.d by the Bay Arca Air ��1�
Quality Management DlsMM7 BOILER-COMP OHP OR 100,000 BTU) FAM
4 Va No
Yread the haze ousmeteriab rrGubement under Chapter 6.95 of BOILERCOMP(OVER 100,0008711) 71g9�
tM Calitorn6 eallh t Safety Code,Settlor 75505,25533 and 75534.1 ^1'
underslandt buldlnBdoes not currently have atenant,that itI.my NEW REM DEN77ALMECH. SQ.FT UCS .
rewthoriwd'
ifytheoccu f e ulrementwhlch Mbemet
paa Certl(1 of �
7, b �1
age t Date
TOTAL: ISSUEDBY: �IU �TR7
OFFICE COPY