20811 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Ad N• �,�. QN�C' �` 20811
hers ame: one: o ~ 1 _ p p q
CITY OFCUPERTINO-BUILDING DIVISION —72-S—GO
• �redor'a Lie.No: APPLICATION I PERMIT 1
ON"
XN BUILDINGELECTRICALPLUMBINGMECHANICAL CATFLORY CONTROL X
rc It /Engineer. Lic. o.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres Isar • I'Fdth9TISSUANCE El 1:1R) ❑
LICENSED CONTRACTOR'S DECLARATION 1�
I hereby affirm m7U( )ofDry licensed under ineasand Pro Chapter9(commwc APPLIANCESRESIDENTIAL JOB DPSCRB'770N
hoemeh in full 70W)of d offeen3.(the Busineseand Prufesslons Code,and my
license I.in full to rad M! s PANELS
Aj If,
Date 1 Lic.p L[J�
Date M 112Z. ,seasContractor yya 2011000AMPS
I understand mr`
RCHbe used DECLAR � N OVER I"AMPS SQ.FT.FLOOR AREA $/SQ.FT.
❑❑❑!
00
y pons shall
be used a public records.
,60 0 Licensed Profesvimul SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIALCTRCUIT/M
p, Ihereby affirm that l am exempt from the Contractor's License law for the
Zt-� following reason.(Section 70115,Business and Professions Code:Any city orp OR IN
county which require.;a permit to corutru"mr,Improve,derrollah,.rrepalr
1�13 any structure prior to its issuance,also requires the applicant for such permitto ppy�ERD CFS
K c file a signed statement that W Is licensed pursuant to the provisions of the
�3 G
Contractor's License Law(Chapter9(commencing with Section 7000)of Ehol. SyMMIN E VALUATION
QQO go.3ofthe Budnessand PrAceskreCde)mthat he is exempt therefromand
p uo�(6 5 the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWI HESHXTURES
fTir'' apphrntforaper tsubjedstheapphcanttoad"lpemltyofnmmmtMn
e. o five hundred dollars($500). JALTER-DRMN
EW RFS( ALELEC SQ.FT. STORIES TYPECONSTRUCTION
.. []I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure V net intended or offered for
psale(Sec.7044,Business and Professlom Code:The Contrad.ea License Law
5� does not a pply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himselforthruugh Msewn employees,provided thatsuch
Improvements arc not Intended oroffered foesale.If,however,thebullding or TOTAL:
Improvement b.old withinoneyearofcompleBon,the owner-budderwill have
tl�+rden of proving that he did net wild or Improve for purpose ofole.). PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensedRMIT ISSUANCE
construct44,
contractors to construct the project(Sec.70Business arad Professro 'COloCode: ��
The Contractors License Law does nat apply to an owner of property who k VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for such toppers with a a
OqDl�+ctor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
. Owner Date �� RECEIPT=
WORKMAN COMPENSATION DECLARATION perry PER TRAP /' SCHOOL TAX Y N
I]I hereby affirm that I have a certificate of consent to wlf-Ins.re,ora 10 RECEIPT
N
ceni(Imeof Workens Comperwtlonlnsuranceoracedifid copythereof(Sec.
M00,Lab C.) S GAEA.SYSIEM-11NC.d OUTLETS PARK FEE Y N
RECEEr1 X
Paltry X GAS EA.SYSIT M OVER 4(FA) BUILDING DIVISION FEES
�m any
[P Certified copy is hereby fumished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' IGREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT. Date Recei t#
(ThissMlon need not be completed lithe permit V forone hundred dollars
($100)or leas.) WATER HEATER W/VFM/ELGCTR Z4� ENERGY FEE Y_ N_
I cenlfytha In the pert....of the work for which this permit Is issued,
1 shall not employ any person In any manner an as to become subject to the WATFdt SYSITM/TRFATING
Workers'Compensation laws of California.Date PAID
OZ Applicant NEWRESIDENTIALPWR. SOFT. Date Recei t#
Z O NOTICE TO APPLICANT.ILafier making this CenBlceteof Exemption,you
should become subject to the Workers'Comperuatlon provisions of the Labor TOTAL:
fp Cde,you rrostfonhwithdunplywthsuchpmWlomorthbpemdtshallbi, BUILDING
dMmed revoked.
I4, FE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I herebyafflrmthatthem Is a construction lendlog agency for the perform ELECTRIC FEE
D Z ance of the work for which this permit is lswdee(S3097,Civ.C.) TOTAL: lba�
02 Ieder'aName 1l PLUMBING FEE f !x00
1L h— lander'sAdd. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mrtlfythat l have readthis appllcatlonad statethat theabove Information
G Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authmize reprewntatives of this
F Z city to enter upon the awvnment+oned property for inspection purposes, ALTER ORADDIO MECH.
_ Date Receipt#
(Ve)agree to save,Inde f4,an d keep harmless the City of Cupertino AIR HANDLING UNIT(7010,000 CFM)
V against 11 Ides,ja dg andexpenwswhich may In ywayaccme SUBTOTAL:
aga bra I Ity In re dihe granting of this
AIR HANDLING UNIT(OVER lO,WOCFM) CONSTRUCTION TAX
Itum
goa .f Ap t/Contractor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI CLOSURE
Will the applicant or future building occupant store or ha ad Is haaardess HEATING UNITED 100,000 BTU) Date ReceI t#
material as defined by the Cu penin.Municipal Cde,Chapter 9.17,and the /�yy
I kalth and Safety Cdr Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: —LaCb
0 Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) �E DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management Dlstrid7, SOMER-COMP OM'OR IOO,(X0 BTU)
4Y. Q No
haveread mialleeth& acusmateriabreons255nbundeaChs nd2S5r6.95of OLER-COMP(OVER 1(0,000BN) JUL
the Glifndt at lithe building
Safety Code,Sectiam currently
25505,25533 a tend 75574.1 lJ
understand that lithe buildingdces nm corrently haveatenant thn itbmy NEW RESIDENTIAL MEC({. SQFf.
responsibility to not lfy the occupant of the requirements which must be and p��sa Of CUDA no
prior to Wua ace of a Certificate of Ocrupa ncy. W4, -=X��J�7,_�
Owner or authorimd agent Date TOTAL: ISSUEDBY:
OFFICE COPY