21075 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
ffullding Project Identification PERMIT NO.
Building Address:
i/ 6 a 572E L i✓ lees 21075
-70614 1 nary ame: 0 6 CITY OF CUPERTINO-BUILDING DIVISION ry �� 0
ontradm'sName: LIc.No: APPLICATION / PERMIT
Architect/Engineer. Lk.Na BNLDINC-EI,ECTRICALPLUMBING-MECliANICAL CATEGORY CONTROL#
- .QTY ELECTRIC PERMIT -1"--FEE BUILDING PERMIT INFO
Address:
PERMITISSUhNCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commaree, APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sectton7000)of Divldon3 ofthe Buslnesnand Professions Co ic,and my
license la In full force and died. PANELS
License Ckse Lie.# `w
Date ContractorUP TO 200 ANTS
ARCHITECPS DECLARATION 271-IODO AMPS
IQ+�Mz Tundentand my plareshaBbe used as public remrds OVERIOOOAMPS _ SQ.Fr.FLOOR AREA f/SQ.Ff.
E ()0 E5
Licensed Proleulonal SIGNSELECTRICAL
EC',I OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Z Fp., Iherebyalflrmthat I am exempt from the Contractor's License Law for the
O q foliowingreason.(Section 70313,Business and Professions Code:Any dtyor
FZt'ry c ntywhlchrequU apermittocomimd,atter,impmwdemollah,orrepaI TFMP.METFR OR POLEI .
q`a 7 anystmmmpdortoltskwance,aborequl theappllunt(orsuch permltm
ES file a signed statement that he 13 licensed pursuant to the pmvbims e( the TOWER DEVICES
i3$L N.
Comredor's License Law(Chapter 9(comn:encing with Section 7000)of Divl- SWRTM NC IOOLEL C
Mona of the Business and ProfeuloreCode)or that he it exempt therefrom.ed VALUATION
�n'g the basis for the alleged exemption. Any violation of Section 7031.5 by any
6X applicant for a permit aubjecia the applicant toadvllpenalty ofnet mcmthan
i
LETSSWITCHESfiveh dnNdollenheprRES[DENTIALEL STORIES TYPECONSIRUCTION
I,asowneroftheproperty,ormy hesemployees with wages r flet sale
m nsatio4,goal he work.anssione odurehe Cont actor or..Law
O d for
uk(Sec.apply
Busbies and f property
rope ty Code:The or improves dm's LIcenae Taw
S$ does not apply roan ownero(prough his o nem oyes,provided
at and OCC.GROUT' R[S.UNITS
who does such work himself cur through his own e.If,ho cel provided that each
Improvements arenot Intended earofred(oleate.ILh ner-q deer buildingorT
Improvement ksold wllhinoneyearofcompldion,rhe owner-bullderwlll love -
tl)akurdce of proving that he did not build or Improve for purpose ofuk.). QTY, PL P 'EpI.00D LONE APN
Lj L as owner of the property,am exclusively contracting with licensed PFRMI.I•LSSU N
contractors to ca"mod the project(See 7014,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property whoALTER-DRAIN A ENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pkajeda with a
drename(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under Sec.TYB k P C for this rename BACK p(A14TFGT.DEVICE OUTSIDE FLLb
Owner DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION FLY.I.URES PER TRAP SCHOOLTAK Y_ N—
❑l hereby ork that I have o certificate
of consent to py the re or a RECEIPT#
c800,lAeofWorken'Comperwtion Insurance ora oertl(kd copy thereo((Sec. - GAS EA.SYSTEM-1 INCAOUTLETS
Polis If C.I PARK PEE Y N
Polity p DING DI N
CoCAS EA.SYSI7MAVER4(EA) BUILDING DIVISION FEES
152"MM.pykfe Mthti cid. CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cert Ned ropy V tiled with the cityInapeotion divlvlon. i
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MOPE Date ReCCI to
(This section need not be completed lithe permit k(orone hundred dollars
(51I Aifyth this WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Isnot mployhe peerson I an tmannerw astobcomamnhkkothesucci, —
I ork not employ any person In any manner n u to become®abject to the WATER SYSTEM/TREATING
Worknre'Campenutlon laws of Call(omle.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you NEW RESIDENTIAL PLMR SQ.FT. - Date Rotel tlif
should becomesubject to the Workers'Compensation provisions ofthe Labor TOTAL: �T
CC Iq Code,you muss forthwith comply with such provisions orthis permit shall be LxCfO
W j deemed revoked ILDI I,
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE t
I hembyafRrmthat there A a construction lending agency for the perform- TOTAL: ELECTRIC FEE
O dace elthe work for which this permit k 097
Issued(Sec.3 ,Civ.CJ
(� Lenders Naar - PLUMBING FEE
1L Lender.Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have reaithkapplicalionand statothatthe above information
S iscormd.I agree to comply with.11 dtyand county ordinances and state laws PERMIT ISSUANCE FEE$PAID:
} W relating to building contraction,and hereby authorize representatives ofthls
F'Z city to enter upon the above-mentioned property for Inspect Ion purposes. ALTER OR ADD TO MECH. Date Recei Ifl
— (We)agree to save,Indemnify and keep harmless the City of Cupertino P
.Batted liabilities,judgments,costa and expenses which my In anyway accrue AIR HANDLING UNIT UO 10,000 CFM) SUBTOTAL:
againalBald City In coneryuen eo the ting this perm
Airs IIANDLINc uNrr(ovEIe 10,000 CFM)
CONSTRUCTIONTAX
SI ruture of AppEcant/Contractor an Date EXHAUSTHOOD(W/DIxT) CONSTRUCTION TAX PAID: '
HAZARDOUS MAYA IALS DISCLOSURE
Will the a ppllunt or future building occupant store or hand le haxardom HEATING UNIT(TO 100,000 BTU) Date RCCCI IM
material as deo net by the Cupertino Municipal Code,Chapter 9.1Z and the - �},
Ilealthand Safety Cocf Sedlon 25532(a)? HEATING UNIT(OVER I W,OW BTU) TOTAL: 2x7V
❑Yes o
Wlllthe applicant er lure building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUV�FAMTE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) R
Yrs y�JN`�o 7 8 7 �(,�(,.�if�l
4h.veread lealthhe Safer mode,Sectionsrequirements 05,25533 and
of BOILER-COMP(OVER 100,00)BN) $E • i�j4
the Calilornk Health k Safety Code,Sections 25505,75533 and 75516. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH, SQ.FT �Q• -
rrsponsibllity to not ify the occupant of the requirements which must be met 'Ise]"'11101f}fivaWw
primto icauanceola Certifica of cmcy
u 907�D
ner or authorised agent Data
TOTAL: ISSUEDBY:`)Tr'1
OFFICE COPY