20951 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identificationh a M//l PERMIT NO.
Building Address: ALfc
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of 3 %CW `MCUAe ' 20951
wnere aces: Q one. A= Tr
CITY OF CUPERTINO-BUILDING DIVISION
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Name: n� ue.N : APPLICATION / PERMIT �J
6UILDINC—MECTRICA4PLIJMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmss: PfRMITISSUANCE 1.11 O ��i' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �J
I hereby Divisiam en3ofthe uMp gandPmfeCha
msnor 9de.and(comment, APPL(ANCFSRFS7DENTWL J08 DESCRIPTION
Ingwlth5ect1on7000)af Dlvialon3o(thc Busin.sand Profosdons Code,and my
Iimnre is In full! afec. PANELS
Llcen Ices N�
Date Contractors —UP TO 200 AMPS
ARCHITECT'S DECLARATION I0I-100OAMPS
�Z (understand myplansshallbeused apublierecords. OVERIOWAMPS SQ.FT.FLOORAREA S/SQ.FT.
y�O
ll Licensed Professional SIGNS ELECTRICAL
<ro OWNER-BUILDER DECLARATION
I hembyat@m that lam exempt from the Contractor's License Law for the SPECIAL CIRCUIT/1,119C
following reason.(Section 7031.5,Bd,inessand Professions Code:Any city or TEMP METER OR POLE(NST.
Qcountywhkh requlresa permittocoadmact,alter,Improve,demolish,orrepair
anystm=mpdartoibt ance,alsorequirestheappBcentfursuchpermitto POWER DEVICES
ce 0. file a signed statement that he Is licensed pursuant to the provisions of the
Owl Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMINGPOOL E TRIC
VALUATION
30 sionlollhe Bu3lne dProfealons Code)orthathe6eumptthemfrom,nd ^7
H E<5 the lads for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC 1 s 1 0
6
applicant fora permR subjecathe applicant to a civil pemlty,of not more than
H
a o flue hundred dollars($500). NEW RESID AL EL
.- F1 I,as owner of the properly,or my employees with wages as their sole SQ.FT. STORIES TYPE CONSTRUCTION
CZa compensation,wtildothe work and thestructure is not intended or offered for
O sale(Sec.7064,Business and Professions Code:The Contractor's License law
$g does not apply to an ownerof propertywho Wildsorimproves thereon,and ( OCG GROUT' RIS.[MI'TS
whodoin suchworkhmu elf orthrough hisownemployees,provided that such
Improver nbamnotlntendedorotferedforule.IQh eer,thebuilding or TOTAL:
Improvementissoldwithinoneyearotcomplet .,theowner-bullderwlllhave
the .,denof proving that he did not Wild or Improve for purpose of sale.). QTY, PL NGT' IT FEE FLOOD ZONE APN
L j L as owner of the property,am exclusively contracting with licensed IT LSSU
contractors m romwet the project(Sec.70K Business and Professore Code:
The Contractors License Law does not apply to an owner of property who p1. -DRAT VENT-
Wilds or Improv.thereon, and who contracts for such ptoject,with a
ne t.[aetar(e)licensed pursuant to the Contractor.License Law. BACK T. CE FEE SUMMARY
15I am exempt under Sec B k P C for this reason
VOP, SANITARY Y N
• Owner Dace DRAT R A N RECEI T N
WORKMAN COMPENSATION DECLARATION F'IX'NRFS TRAP SCHOOLTAK Y N
❑I hereby affirm that I have a mruficate of consent to self-Insure,ora R EIF l'N
certiflcateot Workers'Compensatioulnsurance or a certified copytherem(Sec. GAS EA.SYS'}'EM-I C. O PARK TIE Y N_
3800,Lab C.)
Policy N RECEIPT'N
Com GAS EA.SYSTEM ERd(EA) BUILDING DIVISION FEES
ertified capyisherebyfurnished. GREASE/INDU ASTEIN EP R PLANCHECKFEE
Certified ropy is flied with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA'''EiRAP PAID
COMPENSATION INSURANCE SEINER-SAME -STORM EA p FT Date Remi tfF
Hhissection need not be completed lithe permit is torons hundred dollars
($100)arlea3 WATER HEATER W/VENT/ELEC'IR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhkh this permit is blued,
1 shall not employ an/person in any manner so as to become subject to the WAS SYSTEM/TREATING
Workers'Compenutioelaweof Califomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMe. SQ.FT. Date Recei tq
Z O NOTICE TO APPLICANT:ILafter ma king this Certificate of Exemption,you.
should become subject to the Workers'Comperoation provisions of the Labor TOTAL:
N Code,you most Forthwith comply with such previsbru or this permit shall be BUILDING FEE
W j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL c Ihembya(firmthat there bammtruetion leadingagenry forthe perform TOTAL, ELECTRIC FEE '0
:3 Z anceofthe work forwhkh thin permit is houed(See 3097,CIv.C.) PLUMBING FEE
V O lender's Name
U. F Leader'.Add... QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
OW l mAllythat l Wave read thisappllatbn and statethat theabove Information
1 6coreact.l agree to comply with all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID:
relating to Wilding construction,and hereby authomm representatives of this
I— W city to enter upon the above-mentioned props for inspectionpurposse, ALTERORADDTOMECH.
? (We)agree to uv Indent it kee rmless the City of Cupertino Date ReceiptN
V agaWth.t, ' at.,, est dex whiehm.ylnanywayaccrue AIR HANDLING UNIT(T010,000CFM) SUBTOTAL:
,gains Inc aq re the mgathi.R^"h' CONSTRUCTION TAX
AIR HANDLING I1NIT(OVER tO,ODOCI•'..t)
Si N p can to,do E%HAIJST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA US MATERIALS DISCLOSURE
Will theappllant or Lure building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RmeI tN
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Ilea lth a ad Safety Code fon lIS933(a)? HEATING UNIT(OVER 1Wp00 BTI!) TOTAL:
❑ Yes
Will the applicant or tore building occopam use equipment or devices VFN'DLATION PAN(SINGLE RESID) ISSU/ hDA$'E
widel hazaMousal .mama.at.as defined by the Bay Area Air
Quality Management District? BOILER COMP 0HPOR 100,000 BTU)
4Ycs I� (j
have readthehaza mmaterials requirements under Chapter 6.95 of BOILE&COMP(OVER1W,0008TV) '!� V V 199®
the Cdlifom.1Ix.Rh4[ fety Code,Scotto ,25 1 d75514. I
understandthatifthe bu Bell does not ha ant,that itis my NEW RESIDENTIAL MECH. SQFr
responsibility to n cu ata re Ire. hich most be anti
prior to Lcsuan rtitl I cope
'-j
Owile,oraoLxKsed ric.if TOTAL: ISSUEDBY:
OFFICE COPY