22085 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification I PERMITNO.
Building Addecas: V�t a P � ^ ��_ ry .� ^^O 8 5
oer one. rgeVas J Irl�1111L �- A GAG 11
L DA
'o e: j -T ¢ CITY OF CUPERTINO-BUILDING DIVISION .20 g
Contratt•o.r�.Name: Lie.Na: APPLICATION / PERMIT '4
BUILDING-ELECTRICALMUMBING-MEC MCAL CATEGORY CONTROL N
ArchitM/Engineer. Lk.Noo::
Qn ELECTRIC PERMIT FE/E1a� BUILDING PERMIT INFO
Address: t PERhITISSUANCE s..v/ ❑ _e [I ElLICENSED CONTRACTOR'S DECLARATION
I hereby afftrmthat l em Loosed under provisions of Chapter 9(mmmen APPLIANCESRFSIDENTIAL 103 DESCRIPTION
'ngwith Sedbn700Nof IXVidoa3 afthe Businessand ProfesdonsCode,and my
license is In full fora and effect. r PANELS
Lim
Date
nce�2']_�J Contractor 7J UP TO 2DO ANTS
p]-ROW A.14I'S (1),
ARCHITECTS DECLARATION
p7 I understand my plans shall be used as public records OVERIMAMPS SQ.FT.FLOOR AREA WSQ.IT.
O
ly Licensed Professlovl SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIIRCDIT/MLSC
)' a Ihereby affirm that lam exempt fromthe Contractors License law for the
oo following reason.(Section 7031.5,Business and Profession Code:A yty or d
177AP.MEILR OR POLE INST.
aounty cture requiresa essuan a alcor quims thea pmv,demo)lah,or mit to
g
anystructure statemcartoent
its tuuanegalao sed pursuant
than t the provisionorsuch of t e POWER DEVICES
file a signed statement that M V licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIx6NGNCPOOL ELECTRIC VALUATION
IE O 1n3o11heldneaand Profemiov Code)orthat hebetim therefroand
6 5 the basis for the alleged exemption. Any violation of Section m 70315 by any OUTLETSSWITCIiESFIXTURES
applicant for a permit subjedsthe applicant to a civil penalty of nor morethan
c, five hundred dollars($SM. ILTER-DRAIN&VENT-WATER(EM
EW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
n 1,as owner of the property,or my employees with wages as their sole
�7Q
compensation weldothe work,and thestructure Is not intended or offend for
O sale(Sec 7066,BueLuxs and Profenbv Code:The Contractor•Wave law
$$ don rat apply to an owner of property,who wilds or Improve thereon,and OCC.CROUI' RES.UNITS
who doessuchwork himseVorthrwgh hisawnemployen,provided thatsuch
Improvements are not intended oroffered for sale.If,however,the building or TOTAL:
Improvement lasold within oneyearofcompldion,the owner-builder will have
th rden rf peovingthat he,did rot wild urimprove forpurpona of.le.). PLUMBING PERMIT FEE FLOOD ZONE APN
Lf,as owner of the property,am exclusively contracting with licensedpTp ISSUANCE
contractor to construct the project(Sec 7064,Business and Poco.ov Code:
The Contractor's Llmnse law does not apply to an owner of property who wads or improve meteor, ins who antram for such pRojern wdh dFEE SUMMARY
,tI(actor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTFLT.DEVICE
cc I am exempt under Sec B k P C for thin reason
GRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N�
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION _
ce
hereby allren that I have a certificate of consent to self-insure,ora FD(.IE6 PER IRNP SCHOOL TAX Y_RFGEIl NNN
iBnteo(Workers'CompevationlvumnmoramAifiedmpythereot(Sec. GAS EA.SYSI'FM-1 WC.60ISIi-ETS PARK FEE Y_ N_
3800,lab C.) RECEIPT N
PoligN �r GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
C. dnV �a .u4TG J/I11
�Cered copy b hercbyth the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Certlfied copy b filed with the dty Ivpedlon division.
CERTIFICATE OF UEMPFION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.2(pFT. DB[C RCCCI t#
(Tnlssection need not be completed tithe permit isforonehundred dollars
c91m)orlaaa.) WATERHEATFRW/VENT/ELECTR ENERGY FEE Y_ N_
I mAifythat in the performance of the work frrwhich this permit is tsaued,
1 shall not employ any person In any manner so n to become subject to the WATER SYSCFM/TREATING
Workers Compensation laws of Califomia.Date PAID
O Z Applicant NEW RES DENT AL LMB. �FT.
PDate Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
TCod,you must forthwith comply with such provEsov orthb permit shall be BUILDING FE
CC j deemevoked.
W d reCONSTRUCON LENDING AGENCY SEISMIC FEE
CL
IherebyaffiI
ren that there Is a condracton lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ance of the work for which this perent la anned(Sec.3097,Civ.C.)
02 Lenders Name PLUMBING FEE
LL F- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O Icertify that l have mad this application and state that the above information
O W Lscorrect.I agree to comply with all etyand couetymdlrarresand date laws PERMIT ISSUANCE FEES PAID:
} 4 relating tobullding construction,and hereby authorize representatives ofthis
U) citymenteruUy'do,
-men ed property(or Wpectton purposes. ALTER OR ADDTO MECH.
Date RCccipt#
(We)agra .he
Ify an keep harMev the City of Cupertino AIR HANDLING UNIT(IO 10,000 CFM)
U agabot llabflaad..na xpenses which may in anyway accrue SUBTOTAL:
agaivt said C .oft granting of this permit.
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Slgnxtu App ca tracto Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
OUS MATERIALS DISCLOSURE
Will the app t fu m building occupant store or band le havardous HEATING UNIT CM 100,000 BTU) Date RCceipt#
materlai as deli t pertino Municipa l Code,Chapter 9.12 and the
Health a fid Safety C r Section 25533(a)T HEATING UNIT(OVER 100,00)BTU) TOTAL:
nyea MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) SJ $DANCE DATE
which emit havardoun air contamiv fits as defined by the Bay Arca Air "P-Al ft�f
Quality Management DBtrictT BOILER-COMP OHP OR 1W,IXD BTU) p p �/ }Q_Q
`• Ye [I Na A N ✓ p�7s7
4haee read the Health
&Scow made,Se requirements under Chapter 6.95 of OLE&COMP(OVER 100,W0 BTU)
theerstan t Health building
Code,Sections 25505,25533 a tenant,and25534.I
undertandthat i(the tify Chiding does of the requirc.rushickthatb met NEW RESIDENTIAL MECH. JOFT
rnpovlbsua to notify the occupant of the requlrcmenls which must w met �/ra
prior to Lasuanre ota Certificate of Occupancy. al iM N IIRa'Jp�
J
Owner orawhrrluda t Date t
gen TOTAL: ISSUED BY:
OFFICE COPY