21507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Wentlfication PERMITNO.
Building Address:
Z 0 7 �Ev (2E Qk' . 21507
Name: one: p AL DA rE
wowe v— CITY OF CUPERTINO-BUILDINGDIVISION
GanractoraNam y c� Lic.No: APPLICATION /PERMIT
BU[LDING-ELECTRICAL PLUMBINGMECIIAIx7CAL CATEGORY CONTROLArchited/Eagincer:, Lic.No:
.1 I_ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: / .5'j,
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION El
Eherebyaffbm that l am licensed under provisions of Chapter 9(commenc APPLIANCESRESI)ENTEAL JOB DESCRIPTION
ingwith Se ion7000)of Division3ofthe Businessand PmfemlonsCode,and my
Irons is In fullforceand effect PANELS
License Class
Lit.If SOS/6� - 0( 1.•�
ate Contractor UP TO 200AWS
ARCHITECT'S DECLARATION 201-1000A.MPS w{"�
Z I understand my pha ehaB W used as public reconls OVER 1000AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
O
,,W
qO u Licensed Professional l TRICAL .
6 N OWNER-BUILDER DECLARATION SPECIAL NTT/
f„ I hereby affirm that am exempt from the Contractors License Taw for the
0PF m
following reason. 7031.5,Business and Professions Code:Any-city or TEM .ME LEEN '
countywhich mqulma petitWoonstruct,alter,Improve,demolish,orrepair
aanystmMmpriartoltsiuvamealsorequrstheappUmntforsuchpert tto
0 O file a signed statement that he is licensed pursuant to the provisloru of the
3w� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
sion 3
ivi-slon3 ofthe Business and Pnoeseloro Code)or that he is exempt therefrom and VALUATION
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any OOTL IC FIXIVR
applicant fora perndt subjects theapplicant to a civil penalty of not nnrcthan
five hundred dollars(SM.
Z<
Q1,as owner of the property,or my employees with wages as their sole NEWR A EC SQ.FT. STORIES TYPE CONSTRUCTION
compensation,will do the work and the strut him is not intended or offered for
$' ❑ sa1e(Sec.70K Busbmssint Professions Code:The Contractor's Limat"law
does not apply to ate owner of propertywho Wilds orimproveatheren tad mOCC.GROUP RFS.IATTS
E whodoessuchworkhmaelforthugh hisownemployees,providedthatsuch .
Improvements are not Intended proffered for sale.If,however,thebuildinBur
TOTAL:
Improvement baold within onsyearofcomptelbn,the owner-bu dderwlll have
tI�rdenof proving that he dm not WOd or improve for purpose ofsaleJ. QTY.I PLUMBING PERMIT FEE
FLOOD ZONE APN
Gtr L as owner of the property,am exclusively 0KBusiness
contractNg with licensed PERMIT ISSUANCE r1
The CcMract construct the project(Sec.app]Business and Professions pro oa Code: L.
The heads cur top License law don not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA)
cctato Improves thereon,and who contracts for such p(ojecta with a FEE SUMMARY
coyytjjactmeIlmnzdnder Seto the Contranors License Law. BACK FLOW PROTECT.DEVICE
LJI-am exempt under See. B&P C for Nb reason
OUTSIDE FEES
DRAINS FTODR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date _ RECEIPT If
WORKMAN COMPENSATION DECLARATION
ISI hereby affirm that I have a mFIXTURES-PER IRM SCHOOL TAX Y Nrtificate of consent to self-insure,or RECEIPT'M
certificate of Workers Compeartlon Insurance or a certified copy therarf(See. GAS EA.SYSTEM-11NC.60IJ]LETS PARK FEE Y N
3800,lab CJ RECEIVE If
1'oliry p ./ GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEEr-lB
�Certlfle pybhem turn shed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy l9(fled with the city lapectipn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP. PAID
COMPENSATION INSURANCE SEWER- STORM STOAM EA XIOFT Date Recti t#
(Thissectlon need not be completed If the permit Ls forone hundred dollars
($100),aless.) WATER HEATER W/VENT/ELECTR ENERGY PEE Y N
I certRy that N the penormance ofYhework(or with this permit la Loved,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/.TREATING
Workers Compensation Lawsof CallfomU.Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Rete) t#
Z O NOTICE TO APPLICANT:H,after raking this Certificate of Exemption,you
should become subFct to the Workers Comperustion provisions of the Labor TOTAL:
CC to Code,you.,I fan hwlth comply with such provision or this permit shall be BUILDING FEE
W ] deemed revoked.
TOTAL:
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl Z Ihereby affirm that there is a cotutruction lending agency for the peperform, (� ELECTRIC FEE
:Danre of the work for which this permit b LswN(Se,3097,Civ.C) ��
U O Landers Name PLUMBING FEE
LL I— I.enders Address QTY. MECHANICAL PERMIT FEE MECHANICALFE'E
O W Icerti(y at l have read this applicationand ve
statethat theaboinformitlon
C bcormen. agmto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relatingt building on truction,and hereby authorirs representatives ofthis
F W citytoen ruponthe ve-mentioned property for inspection purposes. ALTEROR ADD TO MECH.
? (We) a to zv Indemnify an p harmless the City of Cupertino Date Receipt#
V agai tl Illtles,' d me and xpenzs which may In anywayamroe AIR HANDL)NG IIMT(TO 111,000 CFM) SUBTOTAL:
agai t sa d City n sequence oft graining of this permit.
/ l AIRHANDLINGUN1T(OVER1o,Im CFM) CONSTRUCTION TAX
Sig App o n
r or Date V ExHA11sT HOOD by/DUCD CONSTRUCTION TAX PAID:
HA7ARDOUSM TERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle harardous HFATINGUNTT(TO100,000BTU) Date Reed t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCode ion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: `
❑Yes
Will the applicant./(cine.Wilding occupant use equipment or devices VENTILATION FAN(SINGLE R 113) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Maagement Dist' ? BOILER-COMP OHP OR 100,000 BTU)
n Y.
.. ��gq110
`{'have acithehvar Ss atcrlabrequime nbunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Calif w Healt & fetyCode,Se,csiva 25505,25533 and 2:534.I
code rsts dthat ift building not currently have a tenant,that it B my NEW RESIDENTIAL MECH. SQ.FT ��� a T1t6'B
r6poai ilitytonot fytheoccups tofthemquhrrm tswhich.d1Ei,met
prior o cant of Cenificamo Occupancy.
Own authori agent . �411a Dats 'TOTAL ISSLTEDLDByBn/YE/p=nrr GGt- au —
OFFICE COPY