20113 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Profen Identification PERMITNO.
Building Address, 20113
fine. A
CITY OF CUPERTINO-BUILDING DIVISION / p 11
to rsN . APPLICATION / PERMIT �! — L (/
IBU LDINGELECTR CALPLUMBINGMECHAMCAL CA RY CO Y ROL M
ed grocer. L Lic.No:
n
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrc PFRMITISSUANCE 1:1 1:1 ❑
LICF.NSF.D CONTRACTOR-5 DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(e mmene- APPLIANCES-RESIDENTIAL 105 DESCRIPTION
Ingwith5mio 7000)m Divtslon3oftheBuaneuandProfred sCde,andery
license 6 in ( d dfect PANELS ^
License Cla Lk.M L
Dat Contndo ]O110DOAMIPS
ARCHITE ION OVERIODOAMPS SQ.Fr.FLOOR AREA /SQ.Fr.
NO0 O I understand my phw shag be u n public records.
&fiO Licensed Profetatoml SIGNSEL TRIC
Z.
OWNER-BUILDER DECLARATION SPEC IA C T/M
Lo., VIhercf0
byarenthat l am exempt fromthe Contractor's Lima.Law for the
QZ- following reason.(Smile.711115.Bualness and Profesabna Code:Any dty or TEMP.M O L
Fcountywhi6requlresapermittocowtmd,xlter,improve,demel6himpair
q'11 anystmdum pdorto its lssuance,also requirestheappllcam for such permit to POWER DEVICES
E C file a signed statement that M 6 Restated pursuant to the provisions of the
�3 Contractor's License I..(Chapter 9(com miming with SMion 70M)of Divi- SWIMMING POOL ELECTR C VALUATION
.
O aon3 ofthe Business and Profemione Code)orthat he Is exam therefromand
S the ba,at for the alleged exemption. Any violation of Section 70)15 by any OUTLETSSWITCHESFIXrURES
applicant fora permit subirds the applkant to a civil penalty of not more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR
[:]1,as owner of the property,or my employees with wages as their sole SQtT' STORIES TYPE CONSTRUCTION
k2a compensation,will do the work and the strudo re 6 not intended or offered for
5 O sale(Sec.7064,Boatman and Professions Cade:The Contractors License Law
$$ docs not apply to an owner of property who build,or improves thereon,and OCC.GROUP RIS.UNITS
doeasuch work himself or through his own employees,provided that such
improvements are not intended oroffered forsals.If,however,thebullding ce TOTAL:
improvement lased withinoneycarofcompleion,theowner Wgderw(have
tryrden of proving that he did net build or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FlppD ZONE APN
ryS as owner of the property,am exclusively contracting with licensed I'QiM1T'LSSUANCE ur
contractors co
to wlruct the project(Sec.7044,Business and Profesdow Code: ` 2.s
Ib c Contnctore License Law doss fiat apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA) •]�i
Wilda or Improves thereon, and who contracts for such pxojecta with a
R
ogOtTaorW licensed pursuant to the Contommr'e License Law. BACK FIAWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason 'FEES
DRAINS FLOOR,ROOF,AREA,COND. ZrOY SANITARY Y N
Owner Date I RECEIPTM
WORKMAN COMPENSATION DECLARATION FIXTURES.PER Py SCHOOL TAX Y_ N_
❑1 hereby af(Irm that I have a certlRcate of consent to self-inwre,or RECEIPT X
certificate of Workera'Compewatlonlwurance or a certified copythereof(Sec. GAS EA.SYSrEfe-I INCA OUTLETS PARK FEE YN
3800,lab C.) _
_RECEIPT N
CUj. M GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
Cenind copy 6 hembytum6hd. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�Cenified ropy6filed with the city lwpectlon division.
CERTIFICATE OF O(EMPHON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE S[WER-SANITARY-STORM EA.2WFT. Date RCCCI t#
(This udion and fid W compldd lithe permit at forme hundred dollars
($100)orlesa.) WATER FIFATERW/VENT/ELECTR 1.Lp ENERGYFEE Y_ N_
1 certify that In the performance of the work forwhlch this permit Is issued,
I shall nm employ any person In any manner se as to become subject to the WATQ4SYSTEM/.TREATING
Workers ns
Compeation Lawsof GOfomla.Date PAID
Z Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. - Date ReCei t#
O should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CCM Code,you most forthwith comply with such provisions or that permit shall be BUILDING FEE
W > deemed revoked.
CL 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there 6 a construction lending agency for the performELECTRIC FEE
Z anceofthework for which this permit beLvmd(Sec.3097,Cie.Q TOTAL: Q_011,
02 Landers Name PLUMBING FEE0-
LL H Lasers Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Icenifyflatl havereadthbappBcaBonand statethattheaboesinformation
IL i cumct.lagrec to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID:
minting to buildpoWletrection,and hereby authodv<representativn of this
F U) city to enter ashes,- Bond property for Inspection purposes. ALTFRORADDIOMECH. Date RCCCIFst#
e) o save a fy an d keep harmless the City of Cupertino
L) I tics,' grrcnts, as and expenses which may In anywayacaue AIRHANDLINGUNIT(rOI0,ODOCFM) SUBTOTAL: (7-U
ag at r me of the grmung of this permit.. AICONSTRUCTION TAX
C� R HANDLING UNIT(OVER 10,000 CFM)
igna or Date aFiAus'r HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAlARDOUS MATERIALS DISCLOSURE
defined
t the upbmidmg«aipal Code,
hhandleh and
HEATING UNIT(TO 100,000 BTU) Date RCCCi t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and SafMyC a ion 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: _O
F-1yeaNo
Will the applicant er7lrura building occupant use equipment or devices VENILATIOM7AN(SINGLE RESID) ISSUANCE DATE
which emit havzdous air cent won as de0ned by the Bay Area Air
T Quality Management t BOILER-COMP pl-1'011 100,0(q BTU)
Yes o 1
I love reed the haza s materials requirements under Chapter 6.93 of BOILER-COMP(OVER00,000 BTU)
theAfla f o e,Sections 25505,25533 and 25536. I
ing a notmmentlyhaveatenangthatitIsmy NEW RESIDENTIAL MEIN. SQFT City of Cupertino
e the pant of the requirements which must be andpraCart teof Occupancy.
or Muth agent~ / Dile TOTAL: ISSUED BY: ^r` I U�•`yC�l
OFFICE COPY