20529 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
• Building Project Identification PL MITNO.
BuOding Address: 20529
Mrs Name: one:
w a�b .- CITY OF CUPERTINO-BUILDING DIVISION
C999ppptract"' Nan c: u".N APPLICATION / PERMIT CC lI//
VLWAdlO BUILDINGELECTRICALML BINGMECHAMCAL CATEGORY CONTROLx
Architect/Engineer. Llc.No:
TY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add PERMITISSUANCE I� ❑ ❑
LICENSED CONT CTOR'S DELLA ION �yJ
I hereby affirm that l am licensed under provblom Chapter9(comsmmc APPLIANCES-RESIDE JOB DESCRB'HON�i, /
ingwlthSenlon7DOO)ofMMsion3oftheBusinemand�sionsC e,and my
PANELS
license is In f.11fe rad effect. .fYVJYItia
License xnsc Class Lir.N
Date �}—CHITS or 2011000 PS
y%de and
ARCHITE OVERT PB SQ.FT.FLOOR AREA $/_ FT.
Oren ]ufider6(a rad myphreahaR be used apubuc records �'
wO SIGNSFL CAL
V�j Licensed Professional
�C� OWNER-BUILDER DECLARATION SPECIALCIR T/
E„ [hereby affirm that l am exempt from the Contractor's License Law for the
7.O^ following reason.(Section 7031.5,Business and professions Code:Any city or
F'n9� =ntywhichmquiresaperMttocowtrucgalter, npmve,demolbh,orrepalr 1EMP.METE[4 LE[NST.
1� .� any structure prior to Its issuance,also requires the applicant for such permit to
C file a signed statement that he,b licensed pursuant to the prowiors of the
Contrano's License law(ChPta erg(mmmenng with Sectl"n 7000)of Divi- VALUATION
w to SWBrtMING POOL ELE C
O scm3 ofthe Bushussand Profenlom Code)orthat he b exempt therefemand
the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
666 applicant for a permit subjects the applicant to a civil penalty of no more than G
five hundred doll..($500). NEW RESIDENTIAL ELECTR
❑1,as owner of the property,or my employees with wages as their sok SQJTr' 511IRIES TYPE CONSTRUCTION
t compensation,will d o the work and the structure is not Intended or offered for
'S p to(Sec.7610 Busbress and Professions Code:The Comrade.Li..e Law
does not apply to an owner of property,who builds or Improve thereon,and OCC.GROUP RES.UMTS
E whodoes suchworkhm I
lforthrough Ithownemplayees,provided thatsua
Imp. :9 are not Intended oroffered forsale.If,however,thewllding or TOTAL:
Improv"ment Iswldwithln oneyearofcompleti"rythe owner-wilderwlll have
thg..¢'den of proving that he did not wild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
FLOOD'lANE APN
U S as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contractors to cere uet the prefect(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who mntram for such pWj es with a ALTER-DRAIN&VENT-WATER(EA)
cq�anor(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L,J 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
fU�TSI DE FEES
Owner Data
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT N
WORKMAN COMP LIVSATION DECLARATION FIXTURES- SCHOOL TAX Y N
❑1 hereby affirm that I have a certi(Icate of consent to self-Insure,ora RECEIPT N
cenificateof Workcm'Compeationls mnce ona certified copythereof(Sec. GAS EA.SYSTEM-1 ING4 OUTLETS PARK FEE Y N
3500,Iab CJ _ �i
1'oliryNm C2( GAS FA.BYSTFM-0VER4(EA) DINGRECEDIVISION
-
Com any15 BUILDING DIVISION FEES
�Cetified here f e GREASE/INDUSI'RL WASTE INTERCEPTOR PLANCHECK FEE
C y!{''ed n'PY b flied wit the city Inspection division.
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID 1 !�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Rece1 t#
(rhlssedion need not be completed lithe permit is forone hundred doll..
($100)or few.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I cenifythat in the performance of thework forwhlch this permit is based,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING a
Workers'Compensation Lassa o(Call(ornla.Date PAID
O Z N
Applicant NEWRE9DEN ALPLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould becomrsubject to the Workers'Comperaat Ion provisions of the Labor TOTAL:
W Cod,you must forthwith comply with such provisions or this permit shall be _ OO
LUFEE
9 deemed CONSTRUCTIONCed. BUILDING CONSTRUCON LENDING AGENCY SEISMIC FEEE
there is
ion lending
CL ]hereby affirm Natichthi aconstwctnued(Sec. 097,Ci C.) perform- TOTAL; ELECTRIC FEE
7 Z ance ofthe work for which this permit bbwed(Sec.309],CIv.C.)
U O LeMer'a Name PLUMBING FEE
LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1tenifythat l have realthbapplication and slatethat theabove Information
M Jammed.I agree to comply with all city and countyordinaems and state laws PERMIT ISSUANCE FEES PAID:
>. relating tobullding construction,and hereby authobterep ativesofthb
F Z city to enter upon the above-mentioned property for I I purposes. ALTERORADDTOMIKIL
Date Receipt#
(We)a ee to save,indemnify and arM he ty of Cupertino V AIR HANDLING UNIT(TO 10,000 CFM)agabatll Ilitles,Pcigmems,cons. n w Inanywayaccue SUBTOTAL:
ag aid City in. ur.m 0 antthl rmlt.
AIR HANDLING UNIT l0,000CFM) CONSTRUCTION TAX
661zSi Contra "r to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR"",A . IALSDISCIASURE
Will the applicant or future wild gompantstoreorlandleha>ardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
Health and Safety CcxIt c`l`n[-2S'32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes . L7"'o
Will the applicant orfmine building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE-DATE
which emit hazardous air contaminants as defined by the Bay Area Air l NiiLA
Quality Management D.grin BOMER.COMP MIP OR 100,000 BTU)
4Yn 1r7T U
havereadthehazer ousmutctabmquirementsunderCh er6.95o[ BOR-ER-COMP(OVQtt00,000 BTU) Jl):�� 1 1 1790
the California Health&Safety Code,Sections 75505,755)7 a 34. I
unde.tan hat if mebulldingdoes not mmx haves na ,thatittamy NEW RESIDENTIAL MECId. SQ.FI'.
'.pont itytona#ytheompantolthesoh muMberet rIry of Cupertiuo
priors ..f.Certifi.t ofO
net or authorized agent to ISSUED OY: XIL Y`�
TOTAL:
OFFICE COPY