21359 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro"ed ldemi(icalor PERMIT NO.
Building Add ress: 6 E .� I3L0ST0VVt be. CjPeA_rIA/o 21359
S C I E�
sacro a `1 • . I p
MIE ( (1J ORIFI I as -�fa(L3 CITY OF CUPERTINO-BUILDING DIVISION G
Corlradora Name: i o Lic.No: APPLICATION /PERMIT B Z
f A,LIT S CATEGORY CONTROL
Arc Be /Engineer. P : No. BUILDING-D.ECTRICA4ML GING-MECHANICAL 2b\
G LEJ (t)/LLIAPM r G•a if BUILDING PERMIT INFO
//a(a dl d � I QrY ELECTRIC PERMIT FEE LOMB.
Address: Y�
1 PERMIT ISSUANCE
LICF.NS BD CONTRACTOR'S DECLARATION
I herebyion7000)of iv Bcrn3 oftheerp Business
sofChapter9dc,and c MPLIANCESRESIDENTIAL ]OB DLSCRIP'f10N
ingwith Section 7000)of ProfessionaCade,and moy
license l.ln lull end cl S,/i/��[/. PANELS
Licenrc Clan is_ Lic.p TT T 7 D j ® � � /�l_pl
Date Contractor 4� FINA �•-- Y
ARCHITBCI'SIARATION 781-]OWAM
q�v Z I understand my pkro shall be used as public records. OVER 1000 __jj SQ.FT.FLOOR AREA S/SQ.FT.
)6 Z.
Licensed Professional SIGNS ELFG CALI 7
Q OWNER-BUILDER DECLARATION SPECIALCIRCAMM V 111 VVV
rm
e ra
Iherebyaffithallam xemptfromthe Contractors License law(w the
7 following mason.(Section 7031 S,Business and Professions Code:Any city or _J
O F..
Kqg1 �
county which requlmapemNt to construct,alter,improve,demolbh,orrepair TEMP.METER OR POLE INST.
Ey a any structure prior to Its Issuance,abo requires the applicant for such permit to (OWER DEVICFS
E Kfile a signed statement that he Is licensed pursuant to the provisions of the
(y Contractor's Liceme law lCha er9(cwmnenco ith Sectlon 7000)of Dlel,
p a w 1n R w SWIMMING POOL ELECTRICLL
p�0 alrn3ofthegusinen and Profession+Code)orlhat hebexempt therefmmand y''� / VAIAATI
6 the basis for the alleged exemption. Any violation of Section 70715 by any OUILETSSWITCHESFIXTURES ` k�30 ,/. D Qr 4
O appllcantfor a permit subjects the applicant to a civil penalty of not morethan VV ll C
(y$ five hundred dollars($500). NEW RESIDENTIAL ELECTR IT.
O? ❑I,as owner of the property,or my employees with wages as their sok SQ' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not Intended or offered for
psale(Sec.7014,Business and Professions Code:The Contractors License law
pjS$ does not apply to an owner of property who Wilds or Improves thereo,and OCC.CROUP RES.UNITSE: who doesauch work hlmanUmthrough his own employee,provided that such
improvementsarenot intended oroffered forsale.IL howevegthebulldingor TOTAL: a,,y•
improvement bwld wlthineneycarofcompletiogthe owner-W Rderwillhave
tltyrden of proving that he did not build or Improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE MildL�I,as owner of the property,am exclusively mmraamg with....d PERMIT ISSUANCE
�a
contractors to mnsUud the project(Sm 7044,Business and Professioru Code: a.x
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such pipjsds with a ism FEE SUMMARY
cgB_l[ador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under Sec. B k P C for this reason
a.(,,a
DRAINS FLOOR A,ROOF,ARECO NO. SANITARY Y_ N_
• Owner Date � RECEIPT N
KM
WORAN COMPENSATION DECLARATION FLXNRES PER.TRAP ` (M SCI IDOL TAX Y_ N_
❑I hereby affirm Thal I have a certificateuVre
certificate of consent to -Insu ,ora L RECEIPT X
cumfinteofWorkers'Compensation Insurance ova certified mpythereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.) RECEIPT X
Policy X GAS EA.SYST@dOVER 4(FA) BUILDING`T VISION IT ES
Com any
�Ce ed ropy b hercbyth the city
CREASE/INDUSTRL WASTE INTIRCEPIOR PLANCHECICFEE 'f
edified copy b filed with the city luuptttion division. �u 9
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA' PAIDIIV72%—'rCD
COMPENSATION INSURANCE SLWER-SANITARY-5fORM EA.2(pFT. Date RCCCI t#
(Thlssectlon need not W completed Ithe permit b for one hundred dollars
($lW)or lens) WATERIIEATERW/VENT/ELECTR ENERGYFEE Y_ N_ 7,0,P
I wdifythat in the performance of the work forwhlch this permit Is Issued,
I shag not employ any person in any runner m ss to become subject to the WAT02 SYSITM/TREAIIN'G
Wwkcua Compensation Gws of Califrrnb. Dace PAID
OZ Applicant NEW RESIDENTIAL PCMB.-SFT. Date Remipt
Z O NOTICE TO APPLICANT-.If,ofter ma king thin Certificate of Exemption,you
should become subject to the Worksm'Compeuuation provisions of the Labor TOTAL:
CC y Code,you most forthwith comply with such provhxom orthls permit shall W BUILDING FEE
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
D Z I hereby affirmthal there baconswdlon lending agency for the perform- TOTAL'50.00 ELECTRIC FEE ♦�
I
of the work for which this permit b blued(&e 3097,Civ.C.)
OO Lender'.Name PLUMBING FEE Oa(�
U. Lendce.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU IcedlfythatlhavereadthkapplicationandstatethattheaW Information [2CdD PEES PAID:
W incorrect.I agreeto comply with all city and county ordlnanceive d state law. ` PERMIT ISSUANCE
} EL relating tobuilding constructor,and hereby authorke mpresentatives oflhb
r N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTD MECH. qs(�
Z (We)agree to save,indemnify an d keep harmiess the City of Cupertino Date RCee1PI#
V against liabilities,Iudgments,coosand expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sold City in come n e ns of the granting of this permit CONSTRUCTION TAX
(� AR HANDLING UNIT(OVER IQODOCFM)
Ig re of is t/Contractor Date IXHAUS'r IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTI) Date Recei l#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the �7
Ilealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER IOQ000 BTU) TOTAL: /tL
❑Yes ri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) LL-t,00 ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DIET OR 100,000 BTU)
Yes No
havereadthe baca ousmateriab requirementsunder Chapler6.95of BORER-COMP(OVER 100,000 BTU) r .scaavY410
the Calllamoa Health k Safety Cod �e,Sections 25505,25533 and 25534. I '4 ,sy'
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
r sponsibllity to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Oaupanq.
Owner or authoriced agent Date TOTAISSUED BY
L: C7�
OFFICE COPY