20638 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preect Identification PERMITNO.
Building Address: n
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ARIA) ERAS 4&i-ClCITY OP CUPERTINOQ BUILDING DIVISION
Ca/n�tra}nr.N.mec ) LIc.No, APPLICATION / PERMIT
!\¢ S 6•REGORy 5332"1BUILDINGELECT3tICALI'LI)MBINGMFAHAMCAL C/v7F-GORY CONTROL0
-• r Architect/Eagiseer. Lie.N.
QTY ELECTRIC PERM FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION ?
Iherebyatflrm thatlam ties nsedunderprovlalonsof Chapaler9(commenc APPLIANCE&RESIDEN9Ik4< JOB DESCRIPTION e
Ingwith Semon 7000)of Mvlelon3 o(the Buelnessand Profeselone Code,and my
license le in full dfcct. ppp PANELS @ \Myr
Grcnse Claes O—I LICN �'—
Date—t!_jI_—ij_�Contractor Q I- 201-1 PS -
lml�)NIW AMPS
ARCHITECTS DEC RATION
re Wp OZ' I understand my plans ehaB be uxd v pub8c remade. OVER 1 SQ.Ff.FLODR AREA I 'S/SQ.Ff.
{2�1r 0 0 Licensed Professional 5 L
OWNER-BUILDER DECLARATION a SP' IRCUI
7�V+� I hereby affirm that am exempt from the Contractor's License Law fort
O .. following reason.(Section 7013,Business and Professions Code:Any city o .M INST.
F F' mntywhichmqur apemdttowmtmct lm
,altir, pmve,demolah,orrepair _
gggOSa anystructure pdorta its lasusnce,also requlresthe applicantforsuch permit t D
ES�a 7 V
file a signed statement that he I.licensed pursuant to the provatom of-the
❑6.3 p� Contractor.License lzw(Chapter 9(commencing with Section 7000)of Divi- LEI.ECIRIC
sion3ofthe Businemand Professlom Code)orthathelsevem themfmmand VALUATION
F• 6 5 ibe balls for the alleged exemption. Any vlWation o(Sectbn 703L5 an
OUTLE 5 TCFIESFIXMtESPplIcs OF1e'•a.�
thcWantforapermit,AItraubjecbtheappl cant to ryvicacivil tloardmltydnamor n
five hundred dollars($500). NEW Br-gohNITAI.ELECTR
❑ _50..17.I,act owner of the property,or my employees with wages a their sole STORIES TYPE CONSTRUCT ION
70. rompensatlon,wilido the work and thestmcture is anal intended or offered for -
g sale(Sec. ppy to alnowand Professions Co Wilds
sCimproves Liernse Law
does not apptytoan ownerofprough his
wnempoy improves alhercaryuch OCC,GROUP, - RES.UNITS
and
whodoemona.a not Intended
nt a dee orwgh hbown employers,provided that such
Improvementsarenotithnondvarofc Tarsale.It ilmo evegthecrwRigve TOTAL:
Improvement.sold wlalhinone yearofcompldlon,alheowner-budderwBl have
al ben ofproving that he,did not bund rimprove forpurpose.teak.). QTY, PLUMBING PERMIT FEE
FLOOD TAKE APN
Lj I,as owner of the
' proam exclusively=trading with PERMIT ISSUANCEcontractor. ocnswctthe project(Sec7osy Business And I'mtesslnssCode:
'
The Contractor's License Law does neral apply to an owner of property who
builds or improves thereon,and who cantncts for such p5ojeem with a AL717t-DRAIN VENT•WATER(FA)
cgntractorIll lemsed pursuant to the Contractor',Lieense Law, FEE SUMMARY
I_J I em exempt under Sec.. 1 B &P C'for this reason BACK PLOW PROTECT.DEVICE
DRAINS.FLOOIy ROOF,AREA,GOND. SANITARY Y N
OUTSI UP FEE
Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLARATIONpp(•(URgS PER TRAPSCHOOL TAX Y N
C0I hereby affirm that I have•artiflrate of consent to see-Insure,ora RECEIPT R
codlfleste a(Workers'Compemationlmnamom ra certified mpythermfelc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38M Lab C.)
PoIIry N_�cep 9005'-9 0 GAS EA.SYSTEM.OVER 4(EA) RECEIVE If
Cg" y N- - BUILDING DIVISION FEES
Certified copy V hemby furnished. CREASE/INDUSTRI.WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE]AAP PAID
COMPENSATION INSURANCESEWER-SAMT'ARY-ST0l2MG 200FT Date Remi t#
(Thlssection need not be completed if the permit afar one hundred dollen
($100)orlem.) • WATER HEATI]t W/VENT/ELFATR - ENERGY FEE Y N
I artRythat in the performanceof the work forwhlch this penmt biomed,
1 shall not employ any person In any manner An as to became subject to the WATER SYSTEM/TREATINGWorkers'Compensation Laws of California.Date - PAID
O Z AppliNOTICE
- NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t#
_Z t,7 NOTICEE 70 APPLICANT-.If,after making this Certificate of Exemption,you
should became subject to the Worker Compensation provbiom of the Labor TOTAL:
F N
Code,you=at forthwith comply with such pavvlsiom or thbpermlt shall be
j dermad revoked: —.BUILDING FEE
LLJa G CONSTRUCTION LENDING AGENCY SEISMIC FEE 5Q
Iherebyaffirm Natthere b a construction leadiagagency forlhe perform- TOTAL: - ELECTRIC FEE
'7O once of the work for which this permit b Issued(Sec.3097,Civ.C.)
V lender's Name PLUMBING FEE
LL F- Lendcr.Addma, QTY. MECHANICAL-PERMIT . FEE MECHANICAL FEE
O Lid
I certifythat l have read this applicattonand slatethalthe above information
d - ban rect.I agree to comply with all city and county ordinances and Mate laws PERMITISSUANCE FEES PAID'
} N rektingtobullding cnmtmcti0e,And hereby authorize representatives ofthb
4— Z city to enter upon the above�meatiomd property for Inspection purposes. . ALTERORADDTOMECH.
_ (We)agree to save,IndemNfy an d loop harmless the City of Cupertino - Date Receipt#
A• sgalnet llabllitles,pdgmenb,cosh and evpensee which rmyln anyway oars, AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
Aga Wt mid City In mnsequena of the granting of this permit.
AIR HANDLING UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
it Signature of Appllant/Contracts Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE rtr'
Will the applicant or(Muse building occupant store or handle hazardous' HEATING UNIT(TO 100,000 BTU) 7
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the - - Date Recel t#
Flea It and Safety Code SMian 7'2P)? HEATING UMT(OVER 100,000 BTU) - TOTAL:
❑ Yes. No
WIlltlu, pllcanto tuturc building occupant u,e equipment or devices VENTILATION PAN(SINGLE RESID) ��IgGUANCE DATE .
which emit hazardous air contaminants as deflmd by the Bay Area Air
Quality Management District? BOfLFR-COMP OTB'OR 100,010 HIM
4Yea ®®No I I 7
have read tha bazardau.mater(ab requiremenbunder Chapter 6.95 of BOILER-COMP(OVfR 100,000 BN) Ury 2 sol Iv9a�V
the Celifmnla Health&Safdy Code,Scctiom 75505,25533 and 25536. 1
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. -
responsibility to notify the occupant of the requirements which swat be oM
pdor to issuance of a Certificate of Ompanry.
�uXn a_�2'�`� 6 r
�i
Owner or authodud agent Date TOTAL: ISSUED BY:
OFFICE COPY