20874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Identification IPERMIT NO..
Building Address: { c t^� ' n 1 we� �. S�1 1 071 o 20874
Owner 9 Name V L� N one: APPLICA PON SUBMI I I p
L DXTE--
^Suw<:p WTVA-6w PW CITY OF CUPERTINO-BUILDING DIVISION
C.Mrseme.Name: Lie.No: APPLICATION / PERMIT L7 l
BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CA=RY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE
rry�� ❑ IPL BUILDING PERMIT INFO
Address: PO MITISSUANCE l W ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�
I hth bdifi7")olamlicensed under sim3ofheBusirosannsof Cssions9(ammrnc APPL[ANCFSRESIDENIUL JOB DESCRIPTION
Ingwith5ect1on7000)of Divislon3o(the9usinnsandS(esslonsCode,and rtry
Iianse la In(u fid effect S I P 'e S i� FSS C9 ) W�O
Lice. lass LIONIf—
Date /Contractor n '�• p1-1000 AMPS
UP TO 2DO ANTS
ARCHITECTS DECLARATION y OVER 1000 AMPS SQ.IT.FLOOR AREA E/SQ.FT.
{Q�OZO Iu d tad yplav Il bail Bubiic remrdw ���
Ez� Lice. Pnefeasloru /—T S7CNSELF!_TRICAL s
Q, �-al`�
«<< m ER-BUILDER DECLARATION
I`n � SPECIAL CIRCUI /M6C
L., y Thereby a((Irm thatlam eaem)a fromthe Contractorb Llanse Law fa the
Or 9 t- following reason.(Section 70315,Business and ProfessionsCode:My city or TEMP METTR OR E INS7
county which requbeaa permit to construct,alter,improve,demolish,or repair `
any structure prior to its Issuance,also requires the applicant for such permit to POWER
file 1 file a signed statement that he es licensed pursuant to the provisions of the
23Ow Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- ) I �� VALUATION
0 slon3ofthe Bus nessandl oe dons Code)orthat he isexampttherefromand SWEd NGK OL ELECTRO
19¢ the basis for the alleged exemption. Any violation of Section 7mt.S by any OUTLE SWIFCHPSFIXM_tES
O applicant lots permit subjects the applicant to a civil pensityafnot morethan
five hundred delta.(55M. NEW R DFNIIAL EL xSQ.F'r. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sok
C7 compensation,will dothe work and the structure V not intended or offered for a
vn ❑ sale(Sec.7042 Business and Professions Code:The Contractors License law
G j$ does not apply to an owner ofpropertywho buildsorimproves thereon,and OCC.GROUT' RFS.UNITS0. who doessuch work himself or through hlsownemployees,provided that such
improvements arena intended or offered fovale.If,however,the building or F TOTAL: J /s00
Improver ntbsoldwithinoneyearofcompleliomtheowner-builderwillhave
tFp-txrrdenofproving that he did not build orimprove forpurposs ofsalc.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
L_I L as owner of the property,am exclusively contracting with license
PERMIT ISSUANCE
contractors to construct the project(Sm 7044,Business and Professions Code:
Ile Contractor's Liars law does net apply to an owner of property who
build.or Inept.therm.,and who contracts for such ylojede with a ALS-DRAW&VENT-WATER MM
ry➢7factor(s)licensed pendant to the Contractor's License Law. FEE SUMMARY
u I am exempt under Sec. aso
B&P C for this ren BAQC FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,ARE&COND. SANITARY Y N—
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y N
QI hereby affirm that I have a certificate of consent to self-Insure,or a RECEIPT N
certificate ofWorkers'Compensation Insurance or a certified copy thereof(Sec. GAS F.A.SYSTEM-1INCAOUTLETS 3800,lab C.) PARK FEE Y N
—
PolicyRECE1PN
CffY GSYSTEM-OVER 4(EM BUILDING DI VISION FEES
Com any
CAS F.A.
ertlfled copy Is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECR FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF FXEM PFION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SM,ffEvtY-sroaM EA 2DIFT Dale Recei l#
(This section need not be completed if the permit b far one hundred dollars
(St00)or lem3 WATER FIFATFxw/vENT/F1.EcrR ENERGYFEE Y— N—
I artlfy that In the Performance of the work forwhich this permit is Wiled,
I shall not employ any person In any manner m ns to become subject to the WATER SYSTEM/TREATING
Wmlwmi Compensation Laws of California.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Dale Re I H!
ZO NOTICE TO APPLICANT.If,a Bretaking aking this Certificate of Exemption,you
should become subject to the Workers'Compensation provblons of the Labor TOTAL:
CCN Code you must forthwith comply with such provisions or this permit shall be I BUILDING FEE
W 7 damned revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M e Z Ihereby affirm that there b a construction lending agency for the perform TOTAL: ELECTRIC FEE
ante ofthe work for which this permit b Issued(See3097,Civ.CJ PLUMBING FEE
V Q Landerb Name
LL F lender'sAaareas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWIscoIartifythatl have read this appliaibnand statethateheabave lnformatlon
1 rren.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building censtrudion,and hereby authorlu representatives ofthas
H N city to enter upon the abovcmentmned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,N pgmems,costs and expenses which may In any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
againstsaldCy a ene,o(th antingo bpermit.
AIR HANDWNG IJMT(OVER 10,000CFM) CONSTRUCTION TAX
�Z 144
Si corm fAppbca t/Cont.; v Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR S MATERIALS DI SCLOS URE
Will the a ppllcant or future building occupant store or ha ad le hamcdom HEATING UNIT CFO t 00,0006TU) Date Revel tN
material as defined by the Cupertino Municipal Code,Chapter 9.1j and the
I lealth and Safety Cod9�tioon 25533(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea ,. y[��,,��1J
Will the applica oto future building occupant use equipment or devices VENTILATION FAN(SINGLE RESl)) ISSUANCE DATE
which emit haresi door air contaminants as defined by the Bay Arca Air
Qua lily Management st 7 BOILER-COMP QHP OR 100,"BTU)
M Yo 0
clave read the hammous matecials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Cod,Sections 75505,XiM3 and 75534. I
underseafid that if the building does not currently have a tenant,that it is my NEIN RESIDENTIAL MECH. SQ.PT.
responsibilayto notify theoceopant of the requirementswhich must be met It.,l IC :/ 'ggp
prket.Wu n a. dlflate ceupsncy. UG
CNA-m, res thorluda t Data ISSUED
S` t
TOTAL:
OFFICE COPY