20199 (2) A"OLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildt.6 Pen'ect Identification PKRMII NO.
e'.w.ng Address:
� o 2 019 9
Mra arM: Onc: APPLICATION SUBMITTAL 5=
P N CITY OF CUPERTINOQBUILDING DIVISION
eontraetor' Name: Lic.Nn: APPLICATION /PERMIT
7. BUILDING-ELECTRICAtePLIIMRINC-MECHANICAL CATEGORY CONTROL
Archil Engineer. LK.No:
QiY�=' `,i. ELECiRICPERMrr' 'I
> 'r�: BUILDING PERMIT INFO
Aaartav: /�. d
le PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby dfirm that am bcmwd under provisions of Chapter9(counere APPLIANCES-RESIDENTIAL JOBD RD j7O
Ingwlt 11 fun7000)of d effeon3oftheBwlrassand Prolnsionv Cade,and D�� (,fit r
limn,x Iv in full! and effect Z PANELS
Llan lam LICN,� IN'r
Dale Contactor 1201.10(K)AMPS T�
ARCHITECTS C ATI- •]
.OZ I understand my pians shall be usedss blicrecerds. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ. .
O
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SI'ECIALCBiCI1IT
I herebya(flrm that l am exempt fromthe Contracur.License law forthe
following reason.(Section 70315,Business and Pmfessbns Code:Any city or
county which requires&permit toconstruct,siterern
,lmptew,dolbh,mmpalr TEMP.METER OR
Q anystsu=mpr rtolGbwance,alsorequr theapph=tforsurhpermlttoPOWQt DEVI
V file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License law lClupter9(commencing with Section 7000)of Divi. NG
'OS Mona ufthellusiness and PrefesslonsCode)orthat he bexempt therefromand %vDAuVALUATION, �0
K' the basis for the alleged exemption. Any violation of Section 70315 by any ODTL SFffSfl10IlA D o
<:gdm
applicant for a permit subjesthe applicant to a civil penalty of not ore than •a Q
five hundred dollars D5W).
0 I,as owner of the property,or ny employees with wages u their sob I NE DENTAL FT. STORES IYPECONSIRUCTION
;ya romFe...tion,wWdothe work and theatsucture is not intended or offered for
O sale(Sec.70K B..i ass and Professions Code:The Contractor.Untrue law
i 3 F don not apply to an owner of property who builds or improves thereon,and mOCC.GROUP RES.ANTIS
whodoosuchworkhi tforthr gh Msownemployees,providedthatmeh •.W
bnproveents are not Intended or offered for sale.If,however,the building or TOTAL;
bnprovementissold wilhlnoneyearofcompldion,theowner-buBderwW have
t"rden of proving that he did eta build or Improve for purpose of sale.). Qiy: �•PI:UMBIN 'PERMIT -':'.FEEvFLooDZDNE APN
LJ L n owner of the Property,am exclusively contracting with licensed
ePERMIT ISSUANCE
contractors to conswct the project(Set 7066,Businss and Professions Code: i
The Contractor's License Law does not apply to an Owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilds Or Improve thereon, and who contneb for such p(ojects with• y�...
�+ctm(U licensed pursuant to the Contraenr.License Law. BACK FLOWPROTECT.DEVICE `''•i':'tw.FEE SUMIvIARY_r""' :,
LJ I am exempt under See B &P C for this reason
••ye Owner Date DRAINS FLOOR,ROOF,AF4 COND. SANITARY Y_RECEIN
WORKMAN COMPENSATION DECLARATION
�„s SCHOOL TAX Y N
QI hereby aRbm that I ism•reMOcare of consardrtifl to copy
ora ' PER TRAP •0 V RECEIPT N
certificate Of Worken'Comperwtlonlnsuranm ora certified copy thereof(Tec. GAS FA.SY El5 PARK FEE Y N
3800,lab CJ
Policy N RECEET N_
Cam ny GAS 4 ) BUILDING DIVISION 1495
�Geniied copy is hereby with
the city
�Certllled copy bfiled with the city inspection division. D INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' At PAID
COMPENSATION INSURANCE RM EA.200E-T. Date Rectal tIt
(Thlssection need not be completed lithe permit b forone hundred doll•
(SIW)orlmJ .I.�W/VENT/ELECTR ENERGYFEE Y N
I mrtlfythat in the Fe,f..ncaaf the wmk forwMch thi.pemdt is
1 shag not employ any person N any manner so sees tp to the WA SYSTEM/TREATING
I hall
emorn n of ymanIfforris. Date��/// PAID
NEW RESIDENTIAL PL.MB. SQFr.
Z Applicant Date Remi tit
O NOTICE :B,after mulling this Certificate of Exemption,you
should become b' othe Workers'Compensatlon provisions ofthe Labor TOTAL:
N Code,you rust forthwith comply with such provisions orthb permlt.hall be D 0
ij deemM revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 1.40
I herebysffirm that then b a construction lending agency for the perform
2 .n..ftheworkforwMchthbper tat swed(Sec.3097,CIv.C.) TOTAL: •� ELECTRIC FEE _
O Ieneet:Name +!.,.,r- r . . PLUMBING FEE
F Lenders Add QTY. - ,iMECHANICA JERMIT?-'• ,.4',FEE.;' MECHANI
IU I mnlfythatl have read thbapplicaticnand statethatthe above information
abwrrect.Iagree to comply with ail city and county ordinances and state laws t PEBIAr ISSUANCE 2.00 FEESPAID:
• W relating to building conslmction,and hereby authorize representative fthis
Z city to enter upon the above-mentioned property for Impecum,purposes. ALTERORADDTOMECK (�
Date Recei tic
(We)agree t,eaIgnent ccatyan experuses"em the Cly o(Cupertino
,rue /�HANDLING IINTT(f0 I0,000CFM)
.goblet WbWtin,jadgmenb,coYO and expenses which mayl nnywayacorue SUBTOTAL:
agar d yin rouse eof the granting ofthis pe
.r �y AIR HANDLING UNIT(OVER I0,000 CFH) CONSTRUCTION TAX
IE
ppBcant on aetor to(/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
N�RDOUSMATERIALSDISC S R
Will the appli rtet or forum building Occupant store or andlch=rdous HEATING UNIT(TO 100,000 BTU) Date RCCCi tic
material as defined by the Cupertino Municipal Coda Chapter 9.12 and the
H,.hh and Safety Code Seaton 15533(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yn MN.
Will the applicant or futum building Occupant use equipment or devims VENTILATION FAN(SINGLE RESID) IS9W&DATE
which eMi harardom air root.Meson as defined by the Bay Area Air
Quality
yn nagementDistrict?ct? BOILER-COMPQHPOR1W,0(DBTU) APR g 195J
lave readlh,b. ous materials requirements under Chapter 6.95 of BOILER-COMP(OVE6 I00,000 BTU)
the California Health&Safety Code,Sections 75505,75533 and 25536.I
understand that if the building don not currently have a tenant,that it is my NINVRS9DEN11ALMECH. SQ.FT as of CIInP,rfino
raponsibllity til notify the occupant of the mqubeomme which rust be Bret
prior to issuanm of a Certificate of Occupancy. �,s
Ownc,m..thmimd.gent Date TornL: . �/\ q l ISSUEDB V
P
OFFICE COPY