20783 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Wentlfls imi PERMITNO.
Build'7DiF Address, Rn rad i w6, 20783
wml. ams: I 11hous:
CITY OF CUPERTINO-BUILDING DIVISION
ge Y
coque rt r'e Name: nl Lk.No APPLICATION I PERMIT
G BUILDING-ELECTRICAL-PLUMBING-MEC1 fAMCAL ONTROLN
Architect/Engineer. Lie.Na:
QT4. ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
lherecdt..mthat lam Bceneed under provWonsol Chapter9(commm APPLIANCES-RESIDENTIAL L JOB DFSCft�I'D� 2 `
Ingwlth5edlan 7000)of Dlvlslon3oftheBusinsmand Profas)onsCode,and my
m end
license Is In full fordied. PANELS
Limes Clam Lin.M
Date d
Contraar
ARCHITECPS DECLARATION 201-1000 AMPS
X
0 Z I understand my plans shall be used as public records. OVER 1000 AMPS - SQ.F7.FLOOR AREA S/SQ,FT.
O
dLicensed Professional SIGNS ELEC CAL
�6 OWNER-BUILDER DECLARATION SPECIALCB2 [
Z,�4I hemby afOrenthat I am exempt from the Contractor's Licenm Law for the
OO following reason.(Section 7871.5,Business and Professions Code:Any city or
counP.MHM LE IN
N� arytywhich requlrtsa permRroconstructire.thspmv,demsuch,orrepair
q any awcturetate entehaa he
almosedline pursuant
to the
fmsuions of lte WERD
[5 m S floe a signed statement that(Chapter Law IlcensN pursuant it the pon 7M) f the
3w sion 3 ofthe LlcerueandPro9(cum)orthag with xemptthe00)of andivi. MI E C VALUATION
O thesiobasis for
thealle ed exemption. Any orthdheb exempt therefrom and
<3
thebasisfarthealleged subjects
p Anyviolationto a civil
of Section lot by any
❑ applicant fora permit subjects the applicant too dull penalty of not more than O TC %TUR 1 CArnt QO
flvegunelred dollars(SM. NEW 91DEVTIALELDCTR .Ff,
STORIES `-�••) TYPECONSTRUCTION
�n �Ij I,as owner of the property,or my employees with wages as their sole
C compensate,will do the work,and the structure is not Intended or offered for
5 O saln(Sec.7044,Business and Professions Code:The Contractor's License Law
does not a pply to an owner of property who builds or improves t hereon,and S OCC.GROUP RFS UNIT
E whodoeaach workMmelf orthrough hisown employees,provided that such
Improvements are not Intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement insold within oneyearofcomple0on,the owner-bu)]der will have
tyw-,.,den of proving that he did net build or Improve for purpose of sale.). QTY, PLUMBING PERMIT,, FEE L7ppD ZONE APN
LJ[as net of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Profemlons Code:
The Contractor's License Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who mdvcta for such pTJeda with e
oRlf+sorts)Bceneed pursuant to the Contnctora Limrse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B&P C for this mason _ OU
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
•, WORKMANRECFBIT is COMPENSATION DECLARATION FB(TURES PER TRAP 5CIiO0L TAX Y_ N_
❑1 hereby affirm that I have• lmumne of.o difi to epytharc,ora RECEIPT M
380illcab ofWorkeri Compensatlonlnsunnce ora certified copy thereof(Sec. GAS PA,SYSTEM-1 INCAOUILEIS - PARK FEE Y N
380Q Lab CJ _
Policy a GAS EA.SYSTEM-OVER 4(EA)' DING DIV
Cam any - BUILDING DIVISION FEES
Certified copy is hereby furnished. GREASE/WDUSIRL WASTE INTEiCEPTOR PLANCI'IECIC FEE
F1 Certified copy la filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORM EA.200FT. Date Reeei tN
(Ihls eneed not he camplded If the perMl lafor one hundred dollars
(5100)or less.) WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
Icertlfythat lnthe performance ofthc work forwNch this pertNtla Wved,
I shall not employ any person In any manner n as to become abject to the WATER SYSIEhf/TREAILNG
Workers'Compensation laws of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLM& SQ.F F. Date Recel tN
O NOTICE TO MPLICANT:I[aflmki
er ang this Certificate of Exemption,you
should become subject to the Works.'Compensation provisions of the Labor TOTAL:
1"' N Cod,you most forthwith comply with such pro,islons or this permit shall be
LU j deemed revoked. BUILDING t. 05 CL GCONSTRUCTION LENDING AGENCY SEISMIC FEE S
I herebyaffirm that there is a mnstmdion lending agency for the perform. ELECTRIC FEE
Z an of the work forwhich this permit la issued(5ec.3097,Clv.C3 L
TOTA
O O lender'.Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT " FEE MECHANICAL FEE
O W dmrtilythat l have read thisapplicatlonand st tethat theabove Information
S incorrect.I agree to complywhie all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r Lgtolouild, construction,and herebyauthorize representatives ofthb
Zenteru nteabove- ntlo propertyforWpedionpurpoaes. ALMORADDTOMECH.
e)agr to ve,Ina Ity n lee Mem the Clty o(Cpertlno Date Receiptfltila Iliesrydgme mat an ex en which maylnanyway.cxmx AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
tsa Ci In cone encs f e rating d this permit.
7 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnaturcof Applicant/Coult600r Date allAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARObS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous FIEATWG UNIT(TO 10),"BTU) Date RCCeI til
material as defined by the Cupertino Municipal Code,Chapter 9,17,and the - —
HealthardSifelyCade dioo 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Will the applicant rfutum building occupant use equipment or devices VENDLATION FAN(SINGLE RESII3) 1$$ A ATE
which emit haxadou air ntaminanteasdefinedbythe Bay Area Alr
Quality Management Ons d7 BOILER-COMPOIAPOR100,00DBTlJ7 4,�� 's O �Q9
4 Yen U
havercadth oun materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California cah&Safety Code,Sections 75585,25573 and 255M.1 /se�o`^
understand) of hebull g rano currently have a tenant,that it la my NEW RESIDEMIAL MECH, SQ.IT. W I/ 44Up(I �
roponsibili to dityt p to t requirementswhichmuatbemd
priortolas are da to fO parry. .
ero uthatls age Date � y..ad .�
TOTAL: ISSUED BY:�
OFFICE COPY