20277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification -II PERMITNO.
B. din A e,a: 2 20277
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ue CITY OF CUPERTINO-BUILDING DIVISION APPLlCAI1n1T9I7MMTrAT A
c °ra°° wK1g1UG6- APPLICATION I PERMIT IS'— \—
BUILDINGELECTRICAI nL RING-MECHAMCAL CATEGORY CONTROL#
A / gi r Lic.Na:
' a U I J�d O QTY ELECTRIC PERMIT FEE BU/LDINGPERMITINFO
A d ail./ ` 4 VQ� PFRMTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(rommenc APPLIANCESRESIDE L JOB DESCRIPTIONu%wlthSooBon7000)of Dlvision3 ofthe Business rad PmfessionsCode,and my
license lain ddfect ('�/ /� PANELS P��.�
Lice,.Cla
Dale Contractor
CHITECPS DECLARATION 201-1000
Pt,qp!!mO zC I understand my plans shall be used as public records. OVER I PS SQ.Fr.FLOOR AREA $/SQ.ET.
E Z U Licensed Professional SIGNS E CAL
<<� to
6 B OWNER-BUILDER DECLARATION PECIALC T/MI
L., � I hm m erebyafOrthat laexempt from the Contractor's License law for the
Z O following reason.(Sectlon 70315,Business and Professions Code:Any city or
O Z t- P.M OR INST.
PE anycoustywhkh requires permne,construct,iresalter,impmvgdemolbhormit to
qq file. uduretotenprior oits haa els.iso sed pursuant to
for aionsch of lite CES
Ei O c.
file a signed statement that M k Licensed pursuant to the provision,of Me
W6Q6 Contractor's License Law(Chapur9(commencing with Section 70W)olDivi.
30re^ n3ofthe Budnessand Profession,Code)orthathelsexem lherefromand G C
s VALUATION
the bask for the alleged exemption. Any violation of Section 701.5 by an
5 appllom
ntfora permit subjects the applicant to a civil penalty of not ore than O HFS
c five hundred dollars%W. NEW RESP AL ELECTR SQFr,
7compensation,
❑I,as owner of the property,or my employees with wages as their sole SfO1R1E5 TYPE CONSTRIX;T'ION
t compensation,will do the work and thestructu re Is not Intended or offered for
O sale f5ec.7044,Business and Prefession,Code:The Contr.ewe,License Law
j$$ does not apply to an owner of property who builds or improves thereat,and
whodoensuch work himself orthrough hisownemployees,provided that such OCC.GROUP RES.IINRS
Impmvementsarenot Intendedoroffen forwle.ILhoweverthebulldingor TOTAL:
Improvement iswld witMnoneyearofcwnpldWmtheowner-builderwill have
the .den of proving that he did not build or improve for purpose ofsak.). QTY, PLUMBING PERMIT FEEp(pp ZONNp ApN
L as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: 1 Lv
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wre
ilds or Improves thereon,and who contracts for such ptojects with a
,�t1I((actor(a)licensed pursuant to the Contractors License Law. BAGK FLOW PROTECT.DEVICE FEE SUMMARY
c L.11 am exempt under Sec. B&P C for this mason
QL2ISIDE F1 I_q
Owner Date DRAINS FLOOR ROOF, REA,NND. (� SANITARY Y_ N_
. L #
WORKMAN COMPENSATION DECLARATION RECEIPT
❑I hereby ffirm that I have a certificste of consent to self-insure,ore A;L FD TURFS PER TRAP � '� SCITOOLTAX Y N
certificate ofWor re'Compen,a In,uranceora certllkd copy thereof(Sec.
RECE�'r#
3800,Lab CJ. n(yJQ ^�1 GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y_ N
RECEIPTCom any c tum/_L sued. 9 CAS EA.SYSTEM-0VER4(EA) #
rtifie c yk erg LT , BUILDING DIVISION FFES
Kj eGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy k fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhissectl.nneed net becompleted lithe permit kforone hundred dollars SEWER-SANTTARY-STORM EA.200FT. Date Remi t#
(S1 W)or less.) WATER HEA / ENERGYFEE Y N_
I OcAllythat in the performance olthe work forwhich this perrrdt Is kaed,
I still not employ any person In any manner a as to become abject to the
Work,ri Compensation Laws of California. Data WATER SYSTEM/TREATING
O PAID
Z Applicant
Z !7 NOTICE TO APPLICANT;If,after making this Certlfiuteof Exemption,you 'NEV RESIDENTIAL PLMB.__SQb7, Date Remi t#
should become subjeet to the Workers'Compensation pcovisiom of the Labor TOTAL:
WW Code,you most forthwith comply with such provision,orthk permit shall be
> deemed revoked. BUIL NG FEE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemby affirm that there k a con,troction lending agency for the perform
Z anceoftheworkforwhichthis permit k Issued(Ser.3097,CIv.C.) TOTAL: n10.[Y1 ELECTRIC FEE
LL O Lender's Name t Y PLUMBING FEE (�k
LL H Lenders Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icert(/ythat l have read thisapplicalion andnatethattheabove Information
ormoxd.lagree to comp)ywith al city and county ordinances and also,laws PERMITISSUANCE FEES PAID:
} W relating to building construction,and herebyauthorUerepresentatiomofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTDMECFL
V _ (NO agno to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,costs and expenses which may In anyway.ecrue AIR HANDLING UNIT fI010,ODO QPM) SUBTOTAL•
agar tsald y aft aming of this nn'.
-��� b AIR HA NULLING UNIT 1Q000CFM) CONSTRUCTION TAX
A�t.tum of Applcenl/Contra or I I I Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
BAZAR DOUS MATERIAL SCLOSURE
Will l the applicant or future building occupant store or ha nd to havardom HEATING UNIT(TO 100,000 BTU)
material.,defined by the Cupertino Mu nicipal Code,Chapter 9.12,and the Date Reeel t#
IIr❑a lta rad Safety Code,Section 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Y.
Will the applicant orroom Wilding om.pant use equipment..devices VEN"DLAHON FAN(SINGLE RESID) 1$$pA E
which emit hnrardous air contamlwnts a,deeded by ted Bay Ares Air
. Quality Management District? BOILER-COMP(3HPOR IOO,IXD BTU)
4 Yes rd No t 7990
haveread the haves Tet madr,ls;Se aqui 25505, 5533underndChapter 25546.95 of BOILER-COMP(OVER 100,000 BTU)
the California I Iealth&Safety Code,Setlloro Z55Q5,25533 and 25536. I
understand that if the building does not currently have a tenant,that it it my NEWRESIDENTIALMECH. 5Q.FT. nr rtl!1P��B�
mant the met
spo bilhyto Oil the pe requireents which most be m
prior issuan enil at o a n '
Own .......died agent Date
TOTAL: ISSUED BY: l/\Y 1'�`I✓'w�^"'
OFFICE COPY