20825 APPLICANT TO FILL IN I ORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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'Z6CITY OP CUPERTINQBUILDINGDIVISION Y^O
Conra res Lie.No: APPLICATION /PERMIT
BUILDINGELECTRICALPLIMBINGMECMNICAL CATEGORY CONTROL
Architect Engincer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: T PERMITISSUANCE El El ElLICENSEDCONTRACTOR'S DECLARATION
I hereby affirm that l am licrosad under provLaons of Chapter 9(aommem APPLIANCES-RESIDENTIAL JOB DFSCRB'77ON
ingwith Section7000)atavlsion3 ofthe Businessand PrefessionsCode,and m
license In In full fog effect �/ �•� PANEI S
Linen Cla Le.p (OJ sl A / V I (
Date I native 201-1000 ANTI'S /"
vv
ARCH ECIARA N
qne 7. I understand my plans.61100'used as public records. OVER 1000 SQ.FT.FLOOR AREA S/SQ.IT.
O
k Ltecaudi Professional SIGNSELEC L -
GGGG G W OWNER-BUILDER DECLARATION x 1
rn Fn SPECIALCIRCWA IMI
I here's form that lamexem fromthe Contractor's License law for the
9 following ream.(Section 70315,Business and Profess..Code:Any cityor TEMP ME OR I. t
rr,Z7 county which requircaa permit to construct,alter,Improve,dernlbh,orrepalr
eM ,,16 anystmcture prior to Rs Lsaance,alsorequirestheappBunt for such perMu° POWER DEVI
r 0 V Rhe a signed statement that he is licensed pursuant to the provisions of the
Commences License law(Chapter 9(commenting with Section 7000)of Divi- MING C VALUATION
O s1m3 ofthe Business and Profewimo Code)orthat he Is exempt therefromand
�i the bas's for the alleged exemption. Any violation of Section 7031.5 by any O .�
ctV xEk
applicant for a permit subjects the applicant to a civil pensltyof not morethan
$ five 1,as
dollars($500).
pr. NEW AL ELEC SQ.FT. STORIES TYPE CONSTRUCTION
J< ❑e a owner of the property,or my employees with wages as their ale
compensation,will do Business workand the stadure Is htC intended oroffend for
5 ❑
does
e(me 7004,Business owner Pro(mbns Code The Contractors Waramarm w
�$$ does nes apply to an owner of property who Wilds or improves lhercaIN
n.and OCC.GROUP RES.UNITS
c. who doessuch work himself orthrough his own employees,provided that such
Improvements are not Intended oroffercd fornale.If,he wevep thebuilding or TOTAL:
Improver ntissoldwithinoneycarofcompletiogtheowner-WOderwill have
tllgkurden of proving that he did not Wild or Improve for purpose ofsakJ. QTY. PL PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed ppRMITISSUAN
commit.to mvtruct the project(Sec 7004,Businessand ProfessionsCode: �d
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN& -WATER
Wilds or improve thereon,and who mamm for such projects with a FEE SUMMARY
,,tIlLSS[[acem(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
1_J f am exempt under Sec B k P C for this reason
OUTSIDEFEES
• Owner Date DRAINS FLOOR ROOF,AREA,COND. u0 SANITARY RECEQrN
WORKMAN COMPENSATION DECLARATION FLY'iURF_S PER TRAF _ DA SCHOOL TAX Y_ N_
M1 hereby affbm that I have o corticate of consent to ytherrc,ora ((rr RECEIPT Y
380itirate of Workers Compensationlnsuranoe oraartl(kd copythereof(See. GAS EA.SYSI'EM-1 INCA OUTLETS PARK FEE Y N
Policy
Y lab CJ RECENT Y
Cumpan GAS EA.SYSTEM-OVER 4(FA)
Com BUILDING DI VISION FEGS
G;Icrtlfird copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Reeei t#
(This section need not be completed if the permit.for one hundred dollars
5100)orlea.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certlfytha in the performance of the work for which this permit Is Issued,
I shall not employ any person in any manner so a to become subject to the WATI]t SYSTEM/TREATING
Workerx'Compensa0an Laws of Gllfomla. Date - PAID
O Z Applicant NEWRESIDENFIALPLMB. SQ FT. Date Rn!EL
Z O NOTICE TO APPLICANT:14 xemp0on
after making this Certificate of E ,you
Fshould become sublet to the Workers'Compermt ion provisions of the Labor TOTAL:
N Coda you at forthwith comply with such provhlons or this permit shall ba BU LNG
FEE
W > deemed revoked.
CONSTRUCTION LENDING AGMCY SEISMIC FEE
E
t7 , I hereby afflrmthat there is a construction lending agency for the perform, rDELECTRIC FEE
a TOTAL:
Z ance of the work for which this permit is Issued(Site3097,Civ.C.) •O
U O L mdar'sName PLUMBING FEE
F Leaders Add. QTY. MECHANICAL PERMIT FEE
O W IsmrIcorify that l haveread this application and statethattheaboveleformatlon MECHANICAL FEE
C et.I agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>• N relating tobullding construction,and hereby authoclue representatives ofthis
Z citytuenterupon the above- turned property for inspection purposes. ALTERORADDTOMECH. Date Receip[#
(We)agree to save,indemnify an d keep harmless the City of Cupertino
V against lab ,judgments,caaand expen hi y in any wayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
agai icy in consequence mf the gra s permit.
^� AIR HANDLING IINTT(OVER l0,000CF1i) CONSTRUCTION TAX
nature of Ap cant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Reaei I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I lealth and Sifcty Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: .(�
❑Yo , MN.
Will the applies of or future bu ild Ing oaupant use equipment or d evim VENTILATION FAN(SINGLE RESID) ISSUANCEiDATE
which meet ham rdoa air cents minants as deft net by the Bay Area Air r] 'I
Quality Management District? BORER-COMP QHP OR 100,0M BTU)
Yes No J JUL 1 Is7s'{Qo
1O
have mail the h.9us materials requirements under Chapter 6.95 of ROLLER-COMP(OVER IOD,DDO BTU)
the Callforna I health h Safety Code,Sections 25505,25S33 and 75510.1
understand that it the building doe mavmntly haveatenanq that ltbmy NEW RESIDENTIAL MECH. SQ.FT
respo A, it o ratify the occupy rift ms which mat be mat Cdy (it/r LI-ndin(1
p' to a mo(aCertlRcatcof ,q /
r+ 3 'A W'
ncr or out sed agent Date ISSUED BY
OTAI,
OFFICE COPY