21871 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
63 5 ;h „ V� VI0 y�1G-031/ 21
871
n ame. one. A A A
g B CITY OF CUPERTINO-BUILDING DIVISIONASOL y f
c°mracc°raNa —L,^ r/Lie.N. APPLICATION I PERMIT —LD
BLRLDING-E,ECTRICALPLLTMBING-MMC LAICAL CATEGORY CONTROL#
�hltect,Engineer. P Lk.No:
L. V /CLL[
QTY ELECCRIC PERMIT FEE BUILDING PERMIT INFO
Address l`o r, PFRMRTISSUANCE115 ❑ E:1LICENSED CONTRACTOR'S DECLARATION
[hereby ethem that l am licmwd under provisions of Chapter 9(commmc APPLIANCFSRESIDENTIAL JOB DFSCRB'HON
Ingwith SWion7000)of Divis m3 ofthe Budnemand PmfesslonsCode,and my
license Is in full force and fect. PANELS
License Class Lk.# I �.–s �6 S� 'VM-4Y'/tI
Date Contractor \ -4
ARCHITECTS DECLARATION 201-1000 AMPS
Fo+03 771 understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT,FLOOR AREA S/SQ.FT,
E (a Llnnsed Profemloml EGNSELECTRICAL
fn ' OWNER-BUILDER DECLARATION SPECIALCRRCUIT/MISC L 7I
Zf, Ihereby affivnthatI am exempt from the Contractor's License Law for the
oo following reason.(Section 70315,Businessand Professions Code:Anycity or
FFpp'ty c°untywhkhrequresapermttwcomwR,alter,Impmve,de=Ush,orrepalr �MP.MEI'ER OR POLE INST.
O�5� a nystmmmpdortoibl ante,alsorequi theappbmntforwc permitto POWER DEVICES
Cn.O Ole a signed statement that M b licensed pursuant to the provokin,of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
slon3 ofthe Business and ProfesslonsCode)orthat he is exempttherefromand VALUATION
Y-' the basis for the alleged exemption. Any violation of Section 7031.5 by any
'Ppu..tfor.permit subjects theappikant toe civil penalty ofn°t morethan OUILETSSWiTCHESFD(URFS
p� five hundred dollars($500). NEWRESIDENTTALELECTR SQFT. STORIES TYPE CONSIR[X:TION
O--�n cue owneerty
r of the prop ,or my employees with wages as their sole
k7a c npensaHon,wOldothe work and thestruGure b not Intended or offend for
5 O sale(Sec.7044,Business and Profosi Code:The Contractors Llmrue Law
ER does not apply to an owner of property who builds or improves therein,and RFSUNITS
-
improvements
who doessuch work himself orthrough his own employees,provided that such OCC-GROUP
Improvements are not Intended oroffered for sale.If,howevegthebuildlogor TOTAL-
improvement b sold within oreyearofcompletbq the owner-buileterwlll have
t Men of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE pLOODZON'E APN
{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 70K Bualnessans nd Professions;Code:
The Contractors License law don not apply to an owner of property who
buALTER DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts such ppices with a
cgDlPidor(s)licensed pursuant to the Contractor's License Law. gp�pLOyy PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec. B&P C for this reason
• Owner Date DRAINS.FLOOR ROOF,ARRA,CONED. SANITN_
KARY Y_
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑/hereby affirm that I have a certificate of consent to sell-Inwre,ora }DCSPERTSP S IUC)L TAX Y_ N
cenlflcate o(Workeri Compensation Wurmes ora artifkd copythereof(Sec. RECEB'T#
MOO,labQ GAS FA.SYSTEM-t INCA OUTLETS PARKFEE Y_ IN
Poll Y
Cam any GAS RA.SYSTEM-OVER4(EA) RECEIPT#
ffCertified copy is hereby fumished. BUILDING DIVISION FEES
❑Certified copy b filed with the city Inspection divlslon. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF E(EMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA.200FT Date RC i t#
IThmsection need out be completed[(the permit V(ororm hundred dollars
(5100)orytha WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
111 certify hatlntheperfo ninaance of th nnerwo tobthlep wb la issued,
I shall not employ an/ Laws in any manner m n to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws Of Call(ornla. Date PAID
0 Z Applicant
Z ONOTICE TO APPLICANT:EL after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__SQFT, Date Recei of
H should bemeaum
bjed to the WOrkers'Copewatlon provisloro of the Labor TOTAL:
W co
Code,you must forthwith comply with such provlslom or this permit shall be
W > decrred revoked. UIL ING FE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirthat there is a construction lending agency for the
0 mperform —ance of the work for which this permit Is Issued(Sec.3097,Civ.C.) TOTAL ELECTRIC FEE
(,) lender.Name PLUMBING FEE
LLT- Lender.Adan,,, QTY. MECHANICAL PERMIT FEE MECHANICAL FBE
O W Icertifythat l have read thisapplicatlonand statethat theabove Information
4 Is coned l agreeto comply with all city and countyordinances and nate laws PERMIT ISSUANCE FEES PAID:
} W relating to building consteuR
ion,and herebyauthonee representatives ofthis
h In city to enter upon the above-mentioned property for Inspection purposes. AL77RORADDTOMECH.
(We)agree to save,IndemNty an d keep harmless the City of Cupertino Date Re ei t#
L.I a Saran iabllltice,pdgmentgmsts dexpenseawhichmaylnanywayaccrue AIR HANDLING UNIT DO 10,000 CFM).g.mt as ty I cons he gr Ing of this pennit.
2_ 7—q AIR HANDLINGUNTT(OVER10,000CFM) CONSTRUCTION TAX
igoature of pl nt "tractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haxardous HFATING UNIT(TO 100,ODOBTu)
material as defined by the Cupertino Municipal Code,Chapter 9.12and the Date Recei t#
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100, ,000 BTU)
❑Yes M No ;A iOTAL:
Will the applicant or future building occupant use equipment or devices VENITATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air rontamiwnts as defined by the Ray Area Av CE D
QualityMmugement DisUfct2 BOILER-COMP OHP OR 100,0(U BTU) gji A
Yes FF��No F{K� /fit
haveeead the hazarYious materials requ urments under Chapter 6.95 of BOILERCOMP(OVER 100,000 BTU)
the Celifemla Health&Safety Code,Stolons 25505,2553]and 25534. I as' R�
understand that lithe building don not avmntly have atenanL that ltbmy=TOTAL:
. I -
r riot to bility to of a Cthe ompant of the requircrrtents which must be roto
prior to Issuance o(a Certificate of Occupancy.
Owneror authorised agent Date
ISSUED BY: 'J t
OFFICE COPY