21533 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification l PFlN9T NO215 3 3
Building Address:(�j(j / �Q�''j��� 1\
Lqq a`l -o"9-Vx _ ""_ C.
f�'
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
[7 4� BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY COMMOL p
No:
At //'�]� + QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
(Ji "3ei—. PFRMITISSUANCE ❑ / ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hembyaffirm that l am lkemed under provisions ofChapter9(rommenc- APPIIANCESRESIDENTLIL / JOB DESCRIPTION
Ingwlib Section7000)o(Dtvlslon3oftbe now essand Professt t-c le,andmy /
license Is in effect. PANELS �� J
License CI k.M -
Date _ Contrad.
RCHITEU 201-1000AMPS
7 I unit tand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
q� O
N oLicensed Professional SIGNS ELECTRICAL
to
G�G OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
F Z Thercbyafflrm that l am exempt from the Contractor's License law for the
2 Ofollowing reason.(Section 7W 1.5,Business and Professions Code;Any city or
rMI"8 cauntywhichrequlresapermittommtmct,alter,bnpmve,de=IWl ,orrepalr T�P'METQt OR POLE
y��s a.yatructure pdorWits issuance,also requiresthe applicant fasuch permit to
file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
6Q O q Contranor's Liceme Law(Chapter9(mmmenang with Section 7000)of Dlvl-
�.�0� sion3ofthe Buslnessand ProfemlomCWe)orthathebeumpttherefmmand SWIMhON LEL C VALUATION
CSpil �d the basis for the alleged exemption. Any violation of Section 7EH5 by any
'u965. applicant fora permit subjects the applicant to a civil penalty ofnat more than OTILETs
five hundred dollars(g500).
Sn -
STOWf3 TYPECONSIRLCTIONr-1I as owner property,or employees with wages as their l sok NEW RESID L eQfT
c peneation,willelothe work and the structure b not intended or offered for
5 O sale(Sec.7044,Bmims i and professions Code:The Contractors License Law
S� does not apply to an owner of property who builds or improves themes,and
RES.IJNRS OCCGROIIIP
who door such work himself orthrough Ms own employees,provided that such
Improvements are not intended oroffemd forsale.If,however,the Wildingor TOTAL:
impmvement lssold Mthinoneyvarofeampletiomthe owner-buBderwill hale
th Men of proving that hedid not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOP ZZONE ppN
{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec,7044,Business and Professions Code: I'11cir
no Contractor's License law does not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contracts such pipjects with a
co,,[[Ld{[Iaeor(a)licensed pursuant to the Contnctors License Law. FEE SUMMARY
I_I I am exempt under Sec. B k P C for this mason BACKFLOW PROTECT.DEVICE •..�\
I DRAINS FLOOR ROOF, N Z-xod SANITARY Y N_
QQT%IDF re
Owner Date p
WORKMAN COMPENSATION DECLARATION RECEIPT
a_FIXTURES-PER TRAP (� � SCI100L TAX Y N
❑I hereby.Rimm that I have a certificate of consent to op thereof
ora a RECEIPT tl
39M,Lcertificaab
Wunnceaaartlfied ropythereo((Sec. GAS.EA SYSTEM-1 INCAOUTLEI'S
380q lab CJ PARK FEE Y N
Pollrytl_w a , A
RECEIPT If
Com nriified cc GAS E4.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certopy is helehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CemlOed ropy b fileded with with the city inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhissection need na becoenplemd lfthepermit tsforonehundred dollars SEVER-SANITARY-STORM EA.20OFT. Date Recei t#
(81 W)otifyth WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N—
Illnify that o any pfomanan tmanner was to b co eesubjecrmit 1.issued, —
1 shall not employ any person In any manner ro m m become subject to the
Worken'Compewtlon Laws of GWATER SYSTEM/TREATING lifornla. Date PAID
O Z Applicant
Z O NOTICETOAPPLICANT:R,aflermaking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQjT', Date Remi t#
'should become subFct to the Workers'Compensation provisions of the Labor
WW Code you roust forthwith comply with such provisions or this permit shall be TOTAL:
> deemed revoked. B 1 ING -E
,(L p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihereby affirm that there is a commm
tction lending agency for the perfor1 s ELECTRIC FEE
.nor of the work for which this permit b tssued(Sec.3097,Civ, TOTAL:C.) L
02 I..deraName PLUMBING FEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE M
O W Imd(fythatlhavcreadthisappuotwn.n S.tethattheabaveinfomution ECHANICAL FEE
a bterrect.I ageeto comply with all city and county ordinances and state laws PERMU155UANCE FEES PAID:
N relating to building construction,and hereby authorize ecpoesentatives alibis
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against Babilltks,pdgments,c stsandexpenseewhkhmaylnanywayamme AIR HANDLING UNIT 10,000 CFM) SUBTOTAL
teal ity ro ce of an[ing of this permit.
!� O AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
S1gnalureof Applicant/ mummer to 7 IXHAUSI'HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Will the applic'morfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
materfalasdefinedbytMCupertino Municipal Code,Chapter9.IZ..dthe Date Recei t#
Health and Safety Cadr ion25532(a)7 HEATING UNIT 100,000 BTU) TOTAL
❑Yea o �a,a.�.r�
Will the a pplicanto forum building occupant use cgWprrcnt or devices VENTILATION FAN(SINGLE RESID) V-w-W"'� DATE
which emit havardom mntaMmmeas defined by the Bay Area Mr �'(rylC.T
® Qualilys agement Dis o BOILER-COMP(3HP OR 100,IXq BT(q -
Yes o (]Q(�
have read the hoz ousmeterialsmquimm nbunder Chapter6.95of BOILER-COMP(OVER100,000 BN) OF U 19 Q
the Callfomia HcalthIk fety Code,Sections 2550.5,25533 and 25534.1 ML
understand that lithe building does not currently have.tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT
Fr to bility tonotifythe oc ant ofthe mqulrementswhich rwsl met ,..a, a,{,tlysasyQ�RR
Fr to ss a n c f anq / j�153 H4l�flVYai
Ownero en /� IDate��
TOTAL ISSUED BY:
OFFICE COPY