21248 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
RnllAdlnod6t s`nig Lq G 21248
eY\�1^^ VI ',"YL 611, one: p
CITY OF CUPERTINO-BUILDING DIVISION
con anne.warTe:— _tt L .Neo APPLICATION / PERMIT
Z�; T N OZ BMDING-ELECnUCALML BINGMECHAMCAL CATEGORY CONTROL A
Architect/Engineer. Llc.No:
�a QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Addrc.s: 4 O tX4 AL POWTISSUANCE El 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I herebyaffbm that l am licensed under provision.of Chapter 9(commene APPLIANCESRFSIDENDAL JOB DESCRIPTION
IngwithSmion7o00)of Divbion3ofthe Buslne.sand Prof.i..Cade,and my
license is io full( and AI M. PANELS a
L=C AIM
L f UP TO 200 ALU!Sl W.
Date Comma"
ARCHITECTS DECLARATION 201-IODOAMPS �Q
µQS rc0 O I understand my plea shall be used as public records. OVER 1000 AMT'S �.FT.FLOOR AR $/SQ.Fr.
EX Licensed Professional - SIGNSELECTRICAL -
dddd 6 re OWNER-BUILDER DECLARATION
Gi 'SPECIAL CIRCUIT/
7po„ Iherebya!@mthat lam31.5,Bfrom
ossa Contractor's License Law Ern the
-
O Z f. loliowing reason.(Section 7031.5,Business and Professions Code:Any dry it TEM TER E INA.
county which requtres a permit to construct,alter,improve,demolish,or repair
$$F�G aQ anystructom priorto Its issuance,abo requlrestheappllant forsuch permit to POWER
C1 ra U file a signed statement that he Is Ikeaed pursuant to the provisions of the
Contradore License Lew(Chapter9(commencing with Section 7000)of Divi- B CCRIC
sion3ofthe BuAnessand Profeastoa Code)mthat hebexemptthAmf mn.mi VALUATION
Othe bash for the alleged exemption. Any violation of Section 70115 by any _
o applicant lora permit subjects the applicant to advilpenalty ofnor mom than O SWI HES 8000
five i,as owner of
he pr). ESID ALE 9Q.FT. STORIES TYPE CONSTRLJCTTON
❑1,as owner of the property,or my employees with wages as their sole
t compensation,wBldothewoProesions Cde:TheC intended eraffercd(or
sale(Sec 7014,Busiau and Pro(enlaa Cade:The Contactor.Lice•..law
dae.natapplyloanowner ofpropertywho Wlld.orimpr .it ereakand OCC.GROUP RESUNIrS
CC.. whodoeseuchworkbimxiforth=ghhisownemptayecs,provldedthatsuch
Improvements are not Intended oroffered for sale.If,howeveq thebulldingor y TOTAL:
Improvement Lssold withinoneyearofcomptmioN theowner-W Bderwlll have
the burden of proving that he did not build or Improve for purpose of saIAL QTY. PLUMBING PERMIT FEE
n L as owner of the property,am exclusively contracting with Ilmmed FLOOD ZONE APN
contractors to construct the proper(See.7074,Business and Professions Code: PELMITISSUANCE
The Contractor's License Law does not apply to An owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such ;najects with a
C' t(actor(s)licensed pursuant to the Contractor's License Law. BACK RIAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOIL ROOF,AREA,COND. SANITARY Y NF
Owner Date ora RECQIT N
WORKMAN COMPENSATION DECLARATION pD(NRES PER TRAP SCIdOOL TAX Y_ N
hereby affirm that 1 have a cmdfiate o!consent to self-Inure, RECEIPT A
'mrtificate of WorYsre'Coenpeneation Insurance ora certified ropythereof(See,
3800,lab CJGAS FA.SYSTEM-1 INC.4OUTLETS PARK FEE Y N'
-,1 q
Policy p W C.Z rro i 0:51#5 j O 1 / GAS P.A.SYSrE1.OVER 4(EA) RECEIPT A
Co fany_(��"W—ft.Aw,sTUA_t BUILDING DIVISION FEES
Certified cop is filedyyth theFFd� GREASE•/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�[Frtified copy b filed with the city inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWPR-5AMTARY-
(Thissedlonnced.m becomplctcd lithe permit bforom hundmddollats STORM EA.200lT. Date Rewi t#
(Sl I untlyssd WATER HEATER W/VENT/m ECTR ENERGYFEE Y N
Icertl(y/hat In the performance a([hework/orwhkhthls permit le Issued,
I shall not employ any person In any Rinner u as to become subject to the WATER SYSTEM/TREATING
Workers'Compensxtton Lawsof California.Date Pplp
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recel t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subrd to the Workers'Compensation provisions of the L.W r TOTAL:
(/3 Code,you most fort hwtth comply with such provisions or this permit shall be
deemed revoked. BB 1 ING F •d
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE A
CL I hereby affirm that there is construction lending agency for the perform ELECTRIC FEE.
Z since of the work(or which this permit is Issued(Sec.3097,Civ.Q TOTAL
V O lender's Name PLUMBING FEE
IL 1— Lendee,Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
OW I cemlylhatl have mad this application and statethat theabove information
fi Iscormet.I ugmeto comply with all city and county ordlnanms and Nate lawn PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthis
Z city to enter upon the aWve-mentimA4 property for inspection purposes. ALTER OR ADD TO MECH. Date RCCCI t#
— (We)agree to save,indemnify and keep harmless the City of Cupertino P
against habllitles ' d,;7 to metsandex sea which mayin anywayamue AIR HAND12NC UMT(TO 10,000 CFM) SUBTOTAL:
agala nronsequence Rf the gr ting of lhls pemdL AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX a �(
Sign of Applies t/Contractor ,e IXHAOST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H ZARDOUS MATERIALS ISCLOSURE
Will the Applicant or future building Rttup nt store or handlchazardous HEATING UNIT(TO 100,000 BTU)
material a defined by the Cupertino Municipal Cods,Chapter 9.1$and the _ Date RCCCI t#
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTLn TOTAL:
r1Yen No
Will the applicant or arum building occupant use equipment or devices VFNTiLATION PAN(SINGLE RENO)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air PAM
Management Distrid7 BOILER-COMP OHPOR 100,000 BTL B
Yes ❑Na
have read the hazardous materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BN)
the Calf/omia Health A Safety Code,Sections 25505,25533 and 25534. I ACT 2 1 .90
understand that lithe Wilding does not camotly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.IT.
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of Certificate of Ocmpanry. /,(«a� N
� f 6 kCC_
�Y
Owner or authorized agent Date ISSUED II}�
TOTAL: *\I�
OFFICE COPY