21047 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address:
21047
Mrs dRC;
753 i 2 CITYOF CUPERTINO-BDING DIVISION
°n 'n r, �� PLICATERMIT
CATEGOqRAYI —�ClyO
6N
TRAOL NAP -MECHANICAL A
A chitea/Engineer. Lic.No:
QTY E P % FEE BUILDING PERMIT INFO
Address:
PERMITIS5U ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ilu,ebyaffirm that l am licensed under provisions of Chapter 9(comrnme- APPLI NC DE JOB DESCRIPTION
ingwith Seaton 7000),aApDIWsion3ofthe Businessand ProfesslonsCode,and my f�
ice IslnmC2YdLic.R' i-9o/<Y6 P CtIZ �.1�7
Date,r Contrador
ARCHITECTS DECLARATION 201.1 AMPS
X I underst0 E5and my plans shall W used as public records. OVER AMPS SQ.FT.FLOOR AREA S/SQ.FC.
E Licensed Pmfessl,nal SIGNSELECTRICAL
<a. OWNER-BUILDER DECLARATION sPECWLCIlRCUIT/MISC
7 Fo'Yha I hereby afRrmthat l am exempt from the Contractors License Law for the
O Z t. following reason.(Section 70)1.5,Business and Professions Code:Any city or gT3.iP METER OR POLE INS(.
l;� county which requlresa permit toconstruct,alter,Improve,demolish,Ormindr
.a anystmcture priorto its Lsnaame,alsorequirestheappilcant forsuch permit to O POWER DEVICES Ee a signed statement that W is licensed pursuant to the provide"of the
Contractors Lice. aw(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRICSOS sion3 ofthe Business and Profemlons Code)orthat he is exempt therefromand VALUATION
Sn the basis for the alleged exemption. Any violation of Seaton 7031.5 by any Q
<
applicant fors permttsubjectstheappifeanof
tioa civil pmaltyn,t moreflan OUTLETS-SWITCHESEXTURES
c. five hundred dollars($SM. NEW REsmENHAL ELFGTR
�n ❑I,as owner of the property,or my employees with wages as their sole SQA STOW ES TYPE CONSIRLX:TION
< compensation,Edi do the work and the structure b not Intended or offered for
n sale(Sec.7064,Business.rad PrefesslOm Code:The Contractors License Law
docs not apply to an owner of property who builds or improves thereon,and
C• whodocasuchwork h+nuelforthrough hisownemp+dyer,provided that such OCC.GROUP RES.UNITS
improvements are not Intended oroffered formle.If,howevegthe building or TOTAL:
improvement issotd withinoneyearofcompteH mtheowner-WBderwilt have
( rdenofpruving that W did not bund or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FIAOzo ZONE ApN
LI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors t,construct the project(Sec,7044,Business and Prorealona Code:
The Contractor's License Law does not apply to an owner M property who ALTER-DRAIN&VENT.WA
Wilds or Improve thereon, and who contracts for such p(ojects with aIEA)
.T5.ctods)Bcensed pursuant to the Contractors License Law. BAOC FLOW PROTECT.EEVICE FEE SUMMARY
LJ I am exempt under Sec. B& P C for this maven
L2151�JLLS
Owner -ate DRAINS FLOOR ROOF,AREA,CONE. SANIFARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT p
C31 hereby affirm that I have a mrti0ote of consent to self-insure,or FIXTURES PER TRAP SCHOOL TAX Y N
anifimteo(WOrk Compen Honlmumnmoracertifiedcopythemof(Sec, RECEPTN
3R00,Lab C.) GAS EA.BYSfEM-1 INCAOUTLETs PARK FEE - Y N
Policy M — RECEIPT M
Com any GAS EA.SYSITTi-OVER4(EA) BUIL DING DIVISION FEES
[Cenlfled copy is hied wahrthe city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the Ay inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thisaeaionneed not Weompleted lithe permit+aforonehundred dollars SEWER-SANITARY-STORM EA."Fr. Date Remi t#
(8100)orlceth) uWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Inilythatthe perfomunceof the work(or which Wmitb Issued
I shall not employ any person in any manner so u to become subjectto the
Workers Compensation Laws of California.Date wArlR syslEd/IREAnex
0 PAID
Z Applicant
Z O NODCETO APPLICANT.If,after making this Cariflate of Exempum,you NEW RESIDENTIAL PLMB. SQ,FR Date Remi t#
Fshould became subject to the Workers Compensation provisions ofthe Labor
WN Code,youmostfOahwithcomplywlthsuchpmWionsorthispermitshallbe TOTAL:
> deP1ned 1ex'°�d' BUILDING FEE w00
O. p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affrrmthat there b m a mmtmdion lending agency for the perform Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
LL O Leader's Name
PLUMBING FEE
drre
L4, H Larder's Address QTY. MECHANICAL PERMIT FEE
O w Icont(ythatlhavadadthlaapphcstbnandstatethattheabove+nformatled MECHANICAL FEE
1 iscomed iagree to complywith all city and countynrdinances and state laws PFRMTTISSUANCE FEES PAID:
>. N relatingtobullding construction,and herebyauthodam representatives ofthis
F- Z city to enter upon the aWve.mentloned property fee inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against llabiiltles,judgments,costsand expenseswhich mayln anyway. roe AIR HANDLING UNIT I0,00o CFM) SUBTOTAL:
agaimtaaid ItyU sequence of th Ban ting Ofthispardit.
9 D ARHANDLNGUN7 (OVERIO,WOCFM) CONSTRUCTIONTAX
s na moi p sant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100p00 BTU)
materia l as defincl by the Cupertino Mu nielpal Code,Chapter 9.12,and the Date Recei t#
Health and Sifely Code Section 25532(a)? HEATING UNIT(OVER]00,000 BTU) TOTAL:
❑Yes O
Will the applianto u reWilding occupant use equipment Ordevices VENTILATION PAN(SINGLE RESIU) 1 CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILFR-COMP QHP OR 100,000 BTU) SEP 1 t5 �yy�
4Yes . rN,
have read theh loos mat coats requirements under Chapter(05 of BOILER-COMP(OVER 100,000 BTU)
the Glifomla Health&Safety Code,Sections 25505,25S33 and 25534.1
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH,
resSQ.FL
responsibility to notify the occupant of the requirements which must be met -�'l CN Lf .it_II(1
prior to issuance of a Certificate of Occupancy.
Ter or authorised agent Date
TOTAL: ISSUED BY; "6/Qiilrl ,
OFFICE COPY